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A  TEXT-BOOK  OF  INSANITY 


A  TEXT-BOOK  OF 

INSANITY 

AND   OTHER  MENTAL  DISEASES 


BY 

CHARLES  ARTHUR  MERCIER 

M.D.,  F.R.C.P.,  F.R.C.S. 

lATE  LECTURER   ON   INSANITY  AT  THE   MEDICAX  SCHOOLS   OV 

THE  WESTMINSTER  HOSPITAL,  CHARING  CROSS  HOSPITAL 

AND  THE  ROYAL  FREE  HOSPITAL 

Author  of  ^'Sanity  and  Insanity" ;  "  Psychology,  Normal  and  Morbid' 
"  Conduct  and  Its  Disorders  "  ;  "A  New  Logic  "  ;  "  Criminal 
EesponsiMlity  "  ;  "  Crime  and  Insanity,"  etc. 
Swlney  Prizeman  for  1909 


SECOND 


EDITION 


ENTIRELY  BE-WEITTEN 

NEW  YORK :  THE  MACMILLAN  COMPANY 

LONDON 
GEORGE   ALLEN  AND   UNWIN,  LTD- 

19U 


First  Edition      .     Feb.  1902 
Second  Edition   .     Sept.  1914 


TO 

SIR  THOMAS  CLIFFORD  ALLBUTT,  K.C.B., 

M.A.,    M.D.,   LL.D.,   D.SC,   F.R.S. 

REGIUS  PROFESSOR  OF  PHYSIC  IN  THE  UNIVERSITY  OF  CAMBRIDGE 

IN   RECOGNITION   OF   HIS  EFFORTS 

TO   PROMOTE   THE   SCIENTIFIC   STUDY   OF  INSANITY 

DURING   HIS   TOO   BRIEF   TENURE 

OF   THE   OFFICE   OF 

COMMISSIONER    IN   LUNACY 


PEEFACE 

TO   THE  FIEST  EDITION,  1902 

Year  by  year  the  students  to  whom  I  lecture  ask  me 
what  book  on  insanity  they  ought  to  study,  and  year 
by  year  I  have  to  recommend  books  which  I  know  to 
be  excellent  in  themselves,  but  which  I  feel  are  of  such 
bulk  and  volume  as  to  be  out  of  proportion  to  the  time 
which  students  can  profitably  give  to  an  outlying 
subject,  and  to  the  vast  mass  of  other  material  which 
they  have  to  assimilate  during  their  brief  curriculum. 
Before  that  important  event  which  took  place  in  the 
year  B.C.  2348,*  medical  students  might  have  spent 
forty  or  fifty  years  in  preparing  for  examination,  and 
have  looked  forward  to  commencing  practice  when 
they  were  entering  their  second  or  third  century,  but 
nowadays  it  seems  incumbent  upon  their  teachers  to 
avoid  discursiveness,  and  I  think  that  our  knowledge 
of  insanity  has  reached  a  point  at  which  its  various 
forms  and  varieties,  like  those  of  bodily  disease,  can  be 
described  as  types,  without  having  recourse  to  descrip- 
tions of  illustrative  cases,  which  bulk  so  large  in  most 
text-books  on  the  subject.  Moreover,  I  was  anxious  to 
put  forward  the  distinction  that  I  have  drawn  in  this 
book  between  forms  of  insanity  and  varieties  of  insanity, 
a  distinction  which  I  think  goes  far  to  solve  the  difficulties 
of  classification  which  have  been  so  great  a  stumbling- 
block  to  successive  writers  on  insanity  for  generations. 

*  According  to  Usshcr,  but  the  Septuagint  has  it  B.  c.  3246. 

vii 


viii  A  TEXT-BOOK  OF  INSANITY 

In  giving  a  preliminary  sketch  of  the  normal  pro- 
cesses of  which  insanity  is  the  disorder,  I  have  followed 
a  course  which  is  very  unusual,  but  which  I  have  pursued 
for  many  years  in  lecturing  on  the  subject,  and  have 
found  to  be  a  very  useful  foundation  on  which  to  build 
a  knowledge  of  insanity.  Special  stress  is  laid  upon 
observation  of  conduct,  which  is  in  my  opinion  the  key 
to  the  subject.  The  causes  of  insanity  have  also  been 
separately  dealt  with,  and  as  I  hold  that  there  are  not 
insanities,  but  insanity  only,  this  course  is  at  once 
convenient  and  logical. 

C.  M. 

Flower  House,  Catford. 


PEEFACE 

TO   THE   SECOND   EDITION 

This  book  was  primarily  intended  for  tlie  use  of  students 
of  medicine,  as  an  introduction  to  the  study  of  insanity, 
to  give  them  a  general  notion  of"  the  subject  without 
going  much  into  detail,  and  incidentally  to  be  of  use 
to  them  in  examinations.  In  this  object  it  succeeded 
so  far  that  it  became,  I  am  told,  the  text-book  in  use 
in  most  of  the  Universities.  It  was  not  intended  as  an 
advanced  book  for  those  who  make  a  special  study  of 
insanity,  and  in  this  respect  also  it  has  not  disappointed 
its  author,  for  the  novel  doctrines  contained  in  it  do 
not  appear  to  have  become  known  to  them  yet. 

In  preparing  a  second  edition,  I  have  addressed  a 
rather  wider  audience.  The  book  will  still,  I  hope,  give 
the  novice  a  general  idea  of  the  elements  of  the  subject, 
but  if  he  is  reading  merely  for  the  purpose  of  preparing 
for  a  qualifying  examination,  there  is  much  that  he 
will  be  well-advised  to  omit.  It  is  never  advantageous 
to  an  examinee  to  know  more  than  his  examiners  about 
his  subject.  The  considerable  additions  that  have  been 
made  to  the  book  are  intended,  not  for  the  general 
student  of  medicine,  who  has  enough  subjects  in  general 
medicine  to  load  his  memory  with  without  adding  the 
superfluous  burden  of  a  knowledge  of  the  constitution 
of  mind  ;  but  for  those,  now  much  increased  in  number, 
who  devote  themselves  temporarily  or  permanently  to 
the  special  study  of  insanity. 
A  2  ix 


X  A  TEXT-BOOK  OF  INSANITY 

Insanity  is  a  subject  but  little  understood.  When  I 
began  to  study  it  there  was  no  systematic  knowledge  of 
it  at  all ;  and  even  now  it  is  considered,  both  by  alienists 
and  in  legal  phraseology,  equivalent  to  disorder  of 
mind,  or  unsoundness  of  mind.  So  regarding  it,  as  I 
was  taught  to  regard  it,  and  as  everyone  but  myself 
still  regards  it,  I  urged  in  my  early  days  that  the  study 
of  insanity — the  disordered  mind,  as  I  then  considered 
it — should  be  preceded  by  the  study  of  psychology — the 
mind  in  health.  The  argument  was  logical  and  reason- 
able, and  unlike  most  of  my  recommendations  this  was 
successful,  but  the  experience  of  many  years  has  made 
me  sorely  regret  my  success.  We  are  all  psychologists 
now.  Many  examining  bodies  grant  degrees  and 
diplomas  in  psychological  medicine,  and  all  that  do  so 
require  of  the  candidates  a  knowledge  of  psychology,  by 
which  they  mean  the  psychology  of  the  text-books  ; 
but  as  a  knowledge  of  text-book  psychology  is  of  no 
more  value  to  the  student  of  insanity  than  a  knowledge 
of  cuneiform  inscriptions,  I  now  contemplate  the  result 
of  my  well-meant  efiorts  with  rueful  dismay  ;  but  still, 
though  my  argument  led  to  this  disastrous  result,  I 
yet  maintain  that  it  was  right  in  principle.  Insanity  is 
of  course  not  the  same  thing  as  disorder  of  mind,  but  it 
contains  a  considerable  ingredient  of  disorder  of  mind  ; 
and  of  mind,  as  of  everything  else,  disorder  cannot  be 
understood  until  order  is  known.  I  have  therefore 
considerably  enlarged  the  chapter  on  Mind,  and  it  now 
contains  an  analysis  and  description  of  the  normal 
mind  specially  adapted  to  the  purposes  of  the  student 
of  the  disordered  mind  and  the  alienist.  The  scheme 
appears  to  be  an  elaborate  one,  but  it  is  the  irreducible 
minimum  necessary  for  the  comprehension  of  disorders 
of  mind  ;   and  though  the  divisions  are  numerous,  the 


PREFACE  xi 

plan  of  division  is  simple,  and  imposes  no  great  burden 
on  the  memory.  Certain  faculties  of  mind — self- 
estimation  and  caution  for  instance — which  are  often 
disordered,  are  here  distinguished  for  the  first  time,  and 
many  disorders  that  have  hitherto  been  confused 
together  are  now  discriminated.  For  instance,  euphoria 
and  exaltation,  dysphoria  and  abasement,  have  never 
been  discriminated,  though  each  of  them  may  occur 
alone,  and  some  of  them  often  so  occur.  The  disentangle- 
ment of  the  highest  level  of  thought  from  its  inferiors 
is  alone  a  justification  for  the  scheme,  for  it  is  disorder 
of  this  limited  constituent  that  distinguishes  insane 
from  sane  disorder  of  mind,  and  that  constitutes  the 
criterion  of  insanity.  It  has  taken  a  quarter  of  a  century 
to  obtain  practical  recognition  of  the  principle  that  the 
study  of  the  physiology  of  mind  should  precede  the 
study  of  its  pathology,  and  it  will  probably  take  another 
quarter  of  a  century  to  substitute  a  fruitful  scheme  of 
the  constitution  of  mind  for  a  useless  one.  I  shall  not 
live  to  see  the  substitution,  but  as  we  grow  older  we 
grow  more  patient  and  more  resigned. 

The  doctrine  that  insanity  is  disorder  primarily  of 
conduct  and  not  of  mind,  manifestly  and  blatantly  true 
though  it  is,  has  made  little  or  no  progress  towards 
acceptance  in  the  twelve  years  since  this  book  was 
published.  My  alienist  colleagues  understand,  when  I 
speak  of  disorder  of  conduct,  that  I  mean  disorderly 
conduct  in  the  police-court  sense.  The  difierence  seems 
to  me  as  plain  as  the  difierence  between,  say,  a  horse 
chestnut  and  a  chestnut  horse,  or  between  £3  10s.  and 
3  lbs.  10  oz.,  or  between  A  and  a  bull's  foot,  but  I  cannot 
get  my  colleagues  to  appreciate  it,  and  it  must  wait  for 
acceptance  until  a  new  generation  takes  their  place. 

Every  writer  on  insanity  has  his  own  classification  of 


xii  A  TEXT-BOOK  OF  INSANITY 

insanity,  and  I  am  no  exception  to  the  rule.  I  am 
exceptional,  however,  in  paying  some  regard,  in  the 
classification  I  propose,  to  the  accepted  canons  of  classi- 
fication. In  the  first  edition  of  this  book  I  formulated 
a  scheme  in  which  an  approximation  was  made  to  the 
separation  of  insanity  the  symptom  from  insanity  the 
disease,  though  the  distinction  was  not  at  that  time 
clear  in  my  mind.  I  was  convinced  that  insanity  could 
not  be  classified  in  a  single  scheme,  because  there  is 
more  than  one  kind  of  fundamental  difference  between 
different  cases,  or  more  than  one  kind  of  kinds  ;  and 
that  the  two  series  must  be  separated  from  one  another 
before  any  satisfactory  classification  could  be  made  of 
either.  The  resulting  arrangement  was  an  advance  on 
previous  classifications,  but  it  was  not  wholly  satis- 
factory, and  no  one  recognised  this  more  clearly  than 
myself.  It  was  unsatisfactory  because  I  did  not  at 
that  time  recognise,  what  has  since  become  clear  to  me, 
that  the  series  is  not  double,  but  triple,  and  that  no 
classification  of  insanity  can  be  satisfactory,  or  free 
from  cross-classification  and  confusion,  that  does  not 
recognise  the  three  concurrent  series  : — symptom,  type, 
and  disease. 

Tried  by  all  the  tests  that  I  have  been  able  to  apply  to 
it,  the  classification  now  proposed  is  watertight.  There 
is  no  inclusion  of  anything  that  is  not  insanity.  Insanity 
is  clearly  distinguished  from  everything  else,  including 
unsoundness  of  mind.  There  has  been  no  attempt  to 
divide  any  class  on  three  or  four  principles  at  once  : 
principles  of  division  have  been  applied  one  at  a  time  ; 
consequently  there  is  no  cross-classification.  Moreover, 
I  think  the  alienist  will  find,  as  I  have  found,  that  the 
kinds  of  insanity  brought  together  in  this  classification 
are  such  as,  from  their  natural  affinities,  we  think  of 


PREFACE  xiii 

together  as  alike,  and  those  that  are  separated  are 
separated  by  a  distance  that  corresponds  with  the 
number  and  importance  of  the  differences  between 
them.  If  a  classification  does  these  things  it  is  a  valid 
classification,  and  does  all  that  is  wanted  of  a  classifica- 
tion. 

The  clinical  descriptions  of  the  various  kinds  of 
insanity  have  been  slightly  elaborated,  but  not  much  ; 
for  in  the  first  place,  our  knowledge  has  not  much 
advanced  in  this  respect  since  the  first  edition  appeared, 
and  in  the  second,  I  kept  in  view  the  primary  object  of 
the  book  as  a  text-book  for  students.  For  examination 
purposes  I  am  afraid  the  book  will  be  to  some  extent 
vitiated  by  the  exclusion  of  the  fashionable  titles  of 
dementia  praecox  and  manic-depressive  insanity  that 
have  of  late  become  so  popular.  I  think  I  was  the  first 
to  point  out  that  mania  and  melancholia  could  not  be 
distinct  diseases,  since  they  were  often  correlated  in  the 
same  case  ;  but  I  did  not  consider  this  the  epoch- 
making  discovery  that  it  is  known  to  be  now  that  these 
cases  are  called  manic-depressive  insanity  ;  nor  do  I 
think  that  the  disease  well  known  in  my  youth  as 
primary  dementia  was  fiirst  discovered  when  it  was 
agglomerated  with  other  disorders  and  called  dementia 
praecox.  Of  the  alternatives  of  conforming  to  what  I 
trust  is  a  passing  fashion  in  nomenclature — there  are  as 
many  fashions  in  medicine  as  in  woman's  dress — and 
giving  what  I  believe  is  a  true  account  of  insanity,  I 
have  chosen  the  latter,  even  though  by  so  doing  I 
prejudice  the  sale  of  the  book. 

Certain  hitherto  unrecognised  kinds  of  insanity  are 
described  for  the  first  time  in  this  book.  The  form  of 
stubbornness  or  resistiveness  was  described  in  the  fiist 
edition.     Some  allusion  to  it  may  be  found  in  other 


xiv  A  TEXT-BOOK  OF  INSANITY 

books  that  have  been  published  since,  but  its  importance 
as  a  distinct  form  of  insanity  has  met  with  no  recog- 
nition. Its  importance  lies  first  in  its  clinical  signifi- 
cance, as  a  very  irrecoverable  form  of  insanity,  and 
second  in  its  remarkable  pathological  affinity  with  para- 
noia, an  affinity  that  is  pathological  only,  and  does  not 
seem  to  extend  to  its  clinical  aspect.  I  was  perhaps  ill- 
advised  in  not  giving  to  it  a  fancy  title.  If  I  had  called 
it  "dementia  recalcitrans "  or  "manic-recalcitrant  in- 
sanity "  it  might  by  this  time  have  been  accepted  as  a 
great  discovery.  The  other  kinds  that  are  here  described 
for  the  first  time  are  the  two  kinds  of  insanity  of  child- 
hood. The  very  important  distinctions  between  the 
various  defects  of  memory  have  never  been  described 
before. 

The  definitions  of  idiocy  and  imbecility  proposed  in 
this  book  have  been  adopted  by  the  Eoyal  College  of 
Physicians,  by  the  Eoyal  Commission  on  the  Feeble- 
Minded,  and  in  substance  by  Parliament,  but  they  have 
not  yet  found  their  way  into  books  on  insanity ;  nor 
has  the  origin  of  these  defects  from  lapse  of  the 
developmental  impetus  yet  been  accepted.  It  will  be 
seen  that  alienists  are  not  precipitate  in  adopting 
novelties  that  originate  in  this  country,  but  in  time — 
in  five-and-twenty  years  or  so — we  may  hope  that 
what  is  manifest  to  everyone  else  will  be  accepted  by 
them.     Meantime,  as  Dr.  Johnson  said,  I  can  wait. 

CHAS.   A.   MERCIER. 

August,  1914. 


CONTENTS 


PA01? 


Introduction    ,  .  .  .  .        .    xvii 

PART  I 
THE  INSTITUTES   OF  INSANITY 

CHAPTER 

I.     The  Causes  of  Insanity         .  ...        3 

11.     Conduct  .  .  ...      27 

III.  Mind  .  .  .  .         .       47 

PART  II 
FORMS,  TYPES,  AND  KINDS  OF  INSANITY 

IV.  The  Classification  of  Insanity  .  .         .115 
V.     Forms  of  Insanity                 .                .  .         .     126 

"VI.     Types  of  Insanity  .  .  .        .174 

Acut«  and  Chronic  Insanity 
VII.     Kinds  of  Insanity  .  .  .        .    209 

Insanity  of  Involution 
VIII.     Kinds  of  Insanity  .  .  .         .    232 

Insanity  of  Dissolution 
Symptomatic  Insanity 
IX.     Insanity  of  Dissolution        .  "    .  .        .     243 

Symptomatic  Insanity 
General  Paralysis 
X.     Symptomatic  Insanity  .  ...     269 

Traumatic  Insanity  .  ...     269 

Insanity  of  Epilepsy         .  .  .         .     271 

XV 


XVI 


A  TEXT-BOOK  OF  INSANITY 


CHAPTER 

XL     Idiopathic  Insanity 

PAGE 

.     278 

Cyclical  Insanity 

.     278 

Fixed  Delusion . 

.     280 

Dementia 

.     292 

XII.    Idiopathic  Insanity 

.     298 

Alcoholic  Insanity 

.     299 

Sequelar  Insanity 

.     305 

Insanity  of  Times  of  Life 

.     305 

Insanity  of  Keproduction 

.     311 

PART  III 
THE  LEGAL   RELATIONS   OF  INSANITY 


XIII. 

The  Legal  Relations  of  Insanity 

.     317 

Certifiability 

.     319 

Placing  and  Keeping  under  Care    . 

.     323 

Testamentary  and  Contracting  Capacity 

.     339 

Criminal  Responsibility  . 

.     340 

APPENDICES 

A. 

—Model  Certificate 

.     342 

B.- 

—Letters  of  Insane  Persons  . 

.     345 

Index 

. 

.     347 

INTRODUCTION 

When  the  student  of  medicine  passes  to  the  study  of 
insanity,  he  crosses  a  scientific  frontier,  and  enters  an 
entirely  new  province  of  knowledge.  Hitherto  his  pur- 
view has  been  limited  to  the  processes  that  go  on  within 
the  body,  and  whatever  references  he  had  to  make  beyond 
that  field  were  indirect  and  of  secondary  import.  He 
needs  to  know  the  structure  and  functions  of  the  several 
organs  of  the  body,  and,  when  any  function  is  disordered, 
his  calling  is  to  take  measures  to  readjust  the  bodily 
processes  to  one  another  so  that  they  may  work  in 
harmony  again.  He  has,  in  short,  to  maintain  the 
organism  in  a  fit  state  to  do  its  work,  whatever  that 
may  be,  but  with  the  doing  of  the  work  he  has  no  con- 
cern. What  the  work  may  be,  and  with  what  efficiency 
it  may  be  performed,  is  no  concern  of  his,  except  in  as 
far  as  these  things  may  afiect  the  general  capability  of 
the  organism  to  continue  its  existence.  His  position 
towards  the  patient  is  the  position  of  the  shipwright 
and  the  engineer  towards  the  vessel  on  which  they  are 
engaged.  Like  them,  he  must  be  thoroughly  acquainted 
with  the  structure  and  function  of  every  part,  and,  like 
them,  he  must  be  upon  the  watch  to  repair  the  structure 
and  correct  the  function,  when  the  one  is  damaged  or 
the  other  is  at  fault ;  but  with  the  ship's  course  he  has 
nothing  to  do.  That  is  a  matter  altogether  beyond  his 
province.  When  the  student  oversteps  the  bounds  of 
medicine  to  enter  upon  the  study  of  insanity,  he  leaves 

xvii 


xviii         A  TEXT-BOOK  OF  INSANITY 

the  engine-room  for  the  quarter-deck.  He  is  no  longer 
directly  concerned  with  the  integrity  of  the  structure  or 
the  efficiency  of  the  engines.  His  function  now  is  to  set 
the  ship's  course,  to  note  the  way  in  which  she  comports 
herself  in  wind  and  weather,  to  study  charts  and  tides, 
stars  and  clouds,  to  watch  the  barometer  and  to  sound 
the  lead,  and  generally  to  relinquish  the  observation  of 
the  ship  herself,  and  to  take  up  that  of  her  relations  to 
the  world  in  which  she  moves.  This  is  the  function  of 
the  student  of  insanity — to  study  the  individual,  not 
per  se,  or  simpliciter,  but  in  relation  to  the  world  in 
which  he  exists,  and  in  which  he  has  to  maintain  his 
existence. 

Insanity  is  often  called  disorder  of  mind,  and  this 
it  is,  but  it  is  much  more  than  this.  Were  it  disorder 
of  mind  alone,  we  should  not  be  called  upon  to  treat 
it ;  for  we  should  know  nothing  about  it  unless  we 
happened  to  be  subject  to  it  ourselves.  What  goes 
on  in  the  minds  of  other  people  we  can  never  know, 
unless  and  until  it  is  revealed  to  us  by  their  conduct. 
Only  by  disorder  of  conduct  can  we  infer  the  existence 
of  disorder  of  mind,  and  when  conduct  is  disordered, 
we  may  safely  and  immediately  infer,  we  are  irre- 
sistibly compelled  to  infer,  the  existence  of  insanity, 
without  stopping  to  investigate  the  condition  of  the 
mind.  If  a  general  officer  goes  on  parade  in  flannels 
and  practising  the  banjo  ;  if  a  parson  goes  into  the 
pulpit  and  plays  cup  and  ball  before  the  congregation  ; 
if  a  hostess  comes  down  to  a  dinner  party  in  her  night- 
dress and  curl-papers  ;  if  a  smith  pulls  a  glowing 
horse-shoe  out  of  the  fire  with  his  naked  hand ;  if  a 
navvy  tries  to  break  up  the  road  with  a  saucepan  ;  we 
do  not  need  to  sit  down  and  investigate  the  state  of 
their  minds  before  we  pronounce  them  insane  ;    the 


INTRODUCTION  xix 

state  of  the  mind  is  left  on  one  side  and  does  not  enter 
into  our  consideration.  We  say  at  once  that  such 
conduct  is  itself  insane,  and  needs  no  further  evidence  to 
establish  the  insanity.  It  is  true  that  there  are  cases, 
many  cases,  in  which  we  do  investigate  the  state  of 
mind,  and  in  which  we  should  not  pronounce  an  opinion 
on  the  sanity  or  insanity  of  the  patient  until  his 
mental  condition  has  been  investigated  ;  but  these  are 
cases  in  which  a  portion,  it  may  be  a  very  large  portion, 
of  the  conduct  exhibits  no  disorder  ;  in  which  the  dis- 
order of  conduct  is  only  occasional,  and  afiects  only  a 
small,  though  it  may  be  an  important,  department  of 
conduct ;  and  in  which  we  have,  perhaps,  no  oppor- 
tunity of  witnessing  any  disorder  of  conduct.  In  such 
cases  we  investigate  the  state  of  mind  in  order  to  dis- 
cover whether  conduct  is  likely  to  exhibit  disorder  ; 
and  it  is  an  index  to  the  Likelihood  of  disorder  of  con- 
duct, not  as  in  itself  exhibiting  disorder,  that  disorder 
of  mind  is  important.  If  we  discover  a  disorder  of  mind 
that  has  no  influence  upon  conduct,  we  cannot  regard  it 
as  an  indication  of  insanity. 

Mind  and  conduct  are  not  the  only  things  disordered 
in  insanity.  The  former  is  a  sign,  the  latter  is  a  symptom, 
of  disorder  of  the  highest  nerve  processes,  whose  function 
it  is  to  actuate  conduct,  and  whose  activity  is  the  con- 
dition under  which  mental  states  arise.  These  highest 
nerve  processes  have  a  double  function.  Not  only  do 
they  actuate  conduct,  and  thereby  regulate  the  whole  of 
the  commerce  between  the  organism  as  a  whole  and  the 
universe  which  environs  it,  but  they  regulate  also  the 
whole  of  the  internal  processes  of  the  body  with  respect 
to  one  another,  harmonise  and  balance  and  preserve 
due  relations  amongst  them.  When  the  highest  nerve 
processes  are  disordered,  therefore,  there  is  disorder 


XX  A  TEXT-BOOK  OF  INSANITY 

among  these  bodily  processes — disorder  which  is  often 
inconspicuous,  but  which,  in  the  deeper  degrees  of 
insanity,  is  often  very  pronounced,  and  exhibits  itself 
in  anomalies  of  skin,  hair,  nails,  sweat,  etc. — superficial 
and  conspicuous  examples  of  a  disordered  metabolism 
which  is  doubtless  present  in  the  deeper  tissues  also. 

Conduct,  however,  is  the  main  thing  that  is  dis- 
ordered in  insanity.  It  is  disorder  of  conduct  that 
gives  to  insanity  its  whole  significance.  Disorder  of 
mind  without  disorder  of  conduct,  if  it  were  possible, 
would  be  unimportant,  if  it  were  important,  would 
be  unrecognisable  ;  and  thus  the  first  essential  to  a 
knowledge  of  insanity  is  an  enumeration  of  the  main 
features  of  conduct,  and  of  the  ways  in  which  conduct 
may  be  disordered. 


PART  I 
THE  INSTITUTES  OF  INSANITY 


CHAPTER  I 


THE  CAUSES  OF  INSANITY 


Whenever  a  meclianism  fails  to  perform  the  duty 
demanded  of  it,  the  reason  must  be  either  that  the 
work  is  too  heavy  for  the  mechanism  or  that  the 
mechanism  is  not  strong  enough  for  the  work  ;  and 
the  two  things  are  not  exactly  the  same.  When  a 
human  organism  breaks  doT;vTi  under  the  stress  of  life, 
in  a  way  that  the  majority  of  men  do  not  break  down, 
it  is  because  either  the  person  who  fails  is  weaker  than 
his  fellows,  or  the  stress  brought  to  bear  on  him  is 
greater.  For  every  person,  as  for  every  beam  and  every 
rope,  there  is  a  breaking  strain.  Load  a  beam  or  a  rope 
with  sufficient  weight,  and,  whatever  its  strength,  it  will 
break  at  last.  Subject  a  man  to  sufficient  stress,  and 
however  well  he  may  be  constituted,  he  will  become 
insane.  In  estimating  the  factors  that  go  to  produce 
insanity  in  any  case,  we  have  to  consider,  first,  the 
person  who  becomes  insane,  and,  second,  the  stresses  to 
which  he  is  subject. 

The  fact  that  the  majority  of  people  are  sane,  indi- 
cates that  they  possess  a  nervous  organisation  of  suffi- 
cient stability  and  strength  to  withstand  the  stresses 
to  which  it  is  subject ;  and  if  here  and  there  one  becomes 
insane,  it  is  because  either  his  nervous  organisation 
was  not  strong  enough  to  withstand  ordinary  stresses, 
or  he  has  been  subjected  to  stresses  of  extraordinary 
severity.    The  great  majority  of  cases  of  ordinary  in- 

3 


4  A  TEXT-BOOK  OF  INSANITY 

sanity  belong  to  the  former  class  ;  cases  of  insanity  of 
drunkenness,  and  of  general  paralysis,  belong  to  the 
latter. 

We  have  no  means  of  gauging  the  efl&ciency  of  a 
person  to  withstand  stresses,  except  by  observation  of 
his  behaviour  under  their  incidence  ;   but,  since  every 
person  is  the  outcome  and  product  of  his  ancestry,  we 
may  make  a  rough  guess  at  his  efficiency  by  investi- 
gating his  heredity.    That  heredity  has  a  very  impor- 
tant part  in  the  production  of  insanity  is  proved,  not 
less  by  clinical  experience  than  by  the  considerations 
just  dealt  with  ;  but  what  it  is  that  is  inherited  in  cases 
in  which  insanity  "  runs  in  the  family  "  it  is  difficult  to 
say.     Insanity   is  manifested  in   conduct,   and   it   is 
evidently  absurd  to  speak  of  what  a  man  is  now  doing 
as  an  inheritance  from  his  forefathers.    The  only  thing 
that  can  be  clearly  conceived  as  transmitted  by  inheri- 
tance is  structure ;  and  if  a  son  "  inherits  insanity  "  from 
his  father,  what  is  transmitted  from  father  to  son  must 
be  some  structural  peculiarity  of  nerve  tissue.    There 
are  several  such  peculiarities  that  may  conceivably  be 
derived  by  inheritance.    In  the  first  place,  the  process 
of  development  may  be  deficient  in  impetus  ;   it  may 
come  to  a  premature  close  ;  and  in  that  case  the  part 
of  the  body  which  will  remain  undeveloped  will  be  the 
part  which  is  the  last  to  be  completed — that  is  to  say, 
the  highest  regions  of  the  brain.     The  degree  of  de- 
velopment which  is  reached  by  these  regions  varies 
much  in  difierent  persons,  according  to  the  strength  and 
persistence  of  the  developmental  impetus.    When  these 
are  exceptionally  great,  the  highest  nerve  regions  be- 
come exceptionally  well  developed,   and   the   person 
attains  to  a  high  level  of  intellectual  development. 
When  the  process  of  development  is  feeble,  and  comes 


INHERITANCE  OF  INSANITY  5 

to  a  premature  close,  the  brain  never  attains  full  develop- 
ment, and  the  person  never  reaches  the  normal  intel- 
lectual standard. 

But  there  are  other  forms  of  insanity  than  idiocy 
and  imbecility,  and  many  of  the  insane  whose  insanity 
"  runs  in  the  family  "  are  of  average,  and  even  of  more 
than  average,  ability.  How  can  we  suppose  that,  in 
such  cases,  the  insanity  is  "  transmitted  "  ?  Or  rather, 
what  is  it  that  is  transmitted  by  inheritance  in  such 
cases  ?  The  analogous  case  of  tubercle  may  help  us 
to  understand.  That  inheritance  has  a  large  share 
in  the  production  of  phthisis  is  as  indisputable  at  the 
present  day,  when  the  tuberculous  process  is  known  to 
be  due  to  the  invasion  of  a  micro-organism,  as  it  was 
before  bacilli  were  discovered  ;  but,  though  it  is  known 
that  phthisis  is  influenced  by  heredity,  it  is  known  also 
that  the  bacillus  is  not  inherited.  What  is  inherited 
is  a  "  delicacy  of  constitution,"  a  "  vulnerability,"  a 
"  feebleness  of  resistance,"  such  that,  when  the  organ- 
ism is  invaded  by  bacilli,  it  has  less  power  to  attack 
and  destroy  them,  they  more  easily  efiect  a  lodgment, 
establish  themselves  and  multiply,  than  they  do  in  the 
tissues  of  a  person  of  stronger  constitution.  And  some 
cases,  at  any  rate,  of  insanity  are  closely  analogous. 
Among  the  stresses  that  do  unquestionably  produce 
insanity  is  that  of  poison  circulating  in  the  blood,  and 
supplied  in  the  pabulum  presented  to  the  nerve  tissue. 
There  is  indisputable  evidence  with  respect  to  some 
of  these  poisons  that  the  nerve  tissue  of  different  people 
has  different  power  of  exclusion  or  of  counteraction. 
No  observation  is  more  trite  than  the  amount  of  alcohol, 
for  instance,  which  will  make  one  man  beastly  drunk, 
will  leave  another  but  slightly  elevated,  and  have  no 
appreciable  effect  upon  a  third.    And  these  differences 


6  A  TEXT-BOOK  OF  INSANITY 

in  the  power  of  the  nerve  tissue  to  exclude  or  to  neutralise 
the  alcohol  that  is  supplied  to  it  are  derived  from  inheri- 
tance. They  are  part  of  the  innate  constitution  which 
the  person  derives  from  his  ancestry.  There  is  there- 
fore nothing  inconsistent  with  experience  in  sup- 
posing that  similar  innate  and  inherited  differences 
exist  in  the  power  of  the  nerve  tissue  to  exclude  or 
neutralise  other  poisons  ;  and  if,  as  is  probable,  many 
cases  of  insanity  are  due  to  the  action  of  poisons  upon 
the  nerve  tissue,  the  influence  of  inherited  quality  of 
nerve  tissue  is  easy  to  understand  in  such  cases. 

But  although  poisons  are  among  the  most  powerful 
stresses  that  the  higher  nerve  regions  have  to  with- 
stand, and  among  the  most  frequent,  they  are  not  the 
only  ones.  As  we  shall  presently  see,  there  are  many 
other  stresses  that  are  provocative  of  insanity  ;  but  the 
way  in  which  inherited  incapacity  renders  the  person 
obnoxious  to  the  action  of  poisons  helps  us  to  under- 
stand the  way  in  which  incapacity,  similarly  inborn, 
may  facilitate  the  occurrence  of  insanity  on  other 
provocation  than  that  of  poisonous  food.  We  see 
similar  differences  in  the  power  of  the  nervous  system 
to  resist  disturbing  agents,  and  to  maintain  equable 
action,  in  other  respects.  We  see  that  the  disaster 
which  will  reduce  one  man  to  despairing  impotence 
will  stimulate  another  to  energetic  activity.  We  see 
that  the  same  insult  which  will  provoke  one  man  to 
uncontrollable  rage  will  be  treated  by  another  with  con- 
temptuous indifference.  And  these  differences,  again, 
are  innate,  and  are  derived  from  inheritance  ;  so  that 
we  can  dimly  understand  how  it  is  that  a  set  of  cir- 
cumstances which  will  produce  insanity  in  one  man 
will  have  no  such  effect  upon  another. 

^0  widely  spread  and  so  strong  is  the  belief  in  the 


INHERITANCE  OF  INSANITY  7 

hereditariness  of  insanity,  that  proposals  are  frequently 
made  to  limit  by  law  the  marriage,  not  merely  of 
persons  who  have  been  insane,  but  of  those  who  have 
insanity  "  in  the  family  "  ;  and  the  expediency  of  such 
marriages  is  a  matter  on  which  medical  practitioners 
are  frequently  consulted.  Such  proposals  are  imprac- 
ticable. If  marriage  is  to  be  prohibited  in  all  cases  in 
which  a  clean  bill  of  health  cannot  be  shown  for  all  the 
individuals  in,  say,  three  generations,  the  practical 
result  would  be  to  prohibit  marriage  altogether  ;  and 
although  the  offspring  of  those  who  have  been  insane 
are  more  likely  to  be  insane,  and  to  have  children  who 
become  insane,  than  are  the  offspring  of  normal  persons, 
yet  it  by  no  means  necessarily  follows  that  such  ill 
results  will  accrue.  The  children  of  any  individual 
who  errs  from  the  general  standard  of  the  race  in  any 
respect  exhibit,  in  the  great  majority  of  cases,  a  return 
towards  the  standard.  The  children  of  giants  are  not 
so  tall,  nor  are  the  children  of  dwarfs  so  short,  as  their 
respective  parents  ;  and  very  many  of  the  children  of 
the  insane  are  as  sound  in  mind  as  they  are  vigorous 
in  body.  Even  when  insanity  is  strongly  prepotent  in 
a  race,  and  when  four  or  five  brothers  or  sisters  are 
insane,  there  is  usually  at  least  one  brother  or  sister 
who  never  shows  a  sign  of  insanity.  The  influence  of 
inheritance  in  producing  insanity  is  great,  but  it  should 
not  be  exaggerated  ;  and  it  would  be  a  gross  exaggera- 
tion to  suppose  that  the  children  of  an  insane  person 
must  necessarily  be  insane. 

There  is  a  widespread  opinion  that  the  children  of 
cousins  german  are  more  prone  to  insanity,  and  es- 
pecially to  weakness  of  mind,  than  other  people.  The 
very  thorough  investigations  of  Mr.  Huth  into  the 
marriage  of  near  kin  have  not  sufficed  to  dispel  this 


8  A  TEXT-BOOK  OF  INSANITY 

opinion,  in  the  face  of  the  occasional  occurrence  of 
idiocy  or  insanity  in  the  offspring  of  persons  so  related. 
That  such  cases  do  occur  is  indisputable,  but  that 
in  very  many  cases  the  offspring  of  cousins  german 
are  as  normal  and  as  well  endowed  as  other  people, 
shows  beyond  question  that  it  is  not  the  mere  existence 
of  blood  relationship  between  the  parents  that  pro- 
duces this  effect.  The  truth  seems  to  be  that  if  there 
is  any  heritable  disposition  in  the  common  family, 
whether  this  disposition  be  to  phthisis,  gout,  cancer, 
insanity,  or  what  not,  the  inheritance  in  the  child  is 
intensified  by  its  derivation  from  both  parents.  The 
same  intensification  would  be  produced  even  were 
the  common  grandparents  destitute  of  any  such  heri- 
table disposition,  if  such  disposition  existed  in  both 
of  the  unrelated  parents  of  the  cousins.  Whether 
the  person  gets  his  morbid  inheritance  from  the  common 
ancestor  of  his  parents  or  from  unrelated  ancestors 
makes  little  difference.  The  important  consideration 
is  whether  he  gets  the  same  kind  of  inheritance — 
inheritance  of  the  same  disposition  or  defect — from 
both  his  parents.  In  such  a  case  the  gravity  of  the 
inheritance  is  more  than  doubled. 

The  stresses  that  produce  insanity  are  of  three 
kinds.  The  first  consists  of  those  in  which  a  disturbing 
agent  acts  directly  upon  the  nerve  tissue  of  the  highest 
regions  of  the  brain  ;  in  which  they  are  bruised  by 
violence,  compressed  by  tumours,  damaged  by  in- 
flammation, or  vitiated  by  the  supply  of  a  poison  in 
the   blood.     These   we   will   call    "  direct   stresses."* 

*  It  should  be  mentioned  that  the  term  "  stress  "  has  of  late  years 
been  used  in  a  sense  diiferent  from  that  in  the  text,  which  was  first 
applied  by  me  in  1890  to  the  agents  that  provoke  insanity.  It  is 
used  to  mean  exercise,  fatigue,  exhaustion  of  nervous  tissue.  The 
former  meaning  has  been  restored  in  the  text. 


DIRECT  STRESSES  9 

Gross  lesions  of  the  brain,  in  their  active  stage,  are 
seldom  attended  by  insanity  in  the  clinical  sense. 
Meningitis,  cerebral  abscess,  cerebral  tumour,  con- 
cussion, fracture  of  the  skull,  wounds,  lacerations  of 
the  hemispheres,  are  attended,  not  by  active  insanity, 
but  by  various  depths  of  coma  ;  and  coma,  though 
scientifically  it  is  a  form  of  insanity,  and  though  it  is 
the  form  which  all  insanities  assume  at  last,  if  they 
go  on  to  the  end,  yet,  since  it  is  not  clinically  regarded 
as  insanity,  need  not  be  dealt  with  here.  Although, 
however,  in  their  active  stages,  gross  lesions  do  not 
produce  clinical  insanity,  yet,  if  they  damage  or  destroy 
convolutions,  this  damage  may  be  evidenced  in  insanity 
when  the  coma  is  sufficiently  cleared  up  for  the  defect 
of  sanity  to  become  recognisable.  In  every  large 
asylum  there  is  a  proportion  of  weak-minded  inmates 
whose  defect  of  mind  is  owing  to  gross  structural 
defect  of  brain,  the  result  of  previous  active  process. 

By  far  the  most  important  of  the  direct  stresses, 
perhaps  the  most  important  of  all  the  stresses  which 
contribute  to  the  production  of  insanity,  is  alteration 
in  the  composition  of  the  blood  by  which  the  highest 
nerve  regions  are  nourished. 

Simple  deficiency  of  nutriment  reduces  the  efficiency 
of  the  function  of  the  nerve  tissue,  which  exhibits 
itself  in  deficiency  of  sanity.  In  starvation  the  mind 
is  weakened  according  to  the  degree  of  the  starvation, 
the  attenuation  of  mind  reaching  to  actual  uncon- 
sciousness when  the  starvation  is  extreme,  and  when 
the  deprivation  of  nourishment  is  complete  and  pro- 
longed. Even  when  it  is  neither,  but  the  heredity  is 
bad,  the  weakness  of  mind  may  be  accompanied  by 
active  insanity.  In  a  large  proportion  of  the  cases 
of  acute  insanity  that  we  have  to  treat,  a  greater 


10  A  TEXT-BOOK  OF  INSANITY 

or  less  degree  of  starvation  Las  been  one  of  the  factors 
in  its  production ;  and  copious  feeding  is  one  of  the 
most  important  modes  of  treatment  of  acute  insanity. 

The  deficiency  in  the  nutritive  supply  of  the  brain 
may  be  due,  not  to  starvation,  but  to  haemorrhage, 
or  to  any  other  condition  in  which  the  blood  is  im- 
poverished ;  and  whatever  the  cause  of  the  impoverish- 
ment, the  deterioration  of  sanity  is  the  same,  provided 
the  impoverishment  is  the  same  in  degree,  and  the 
resistive  power  of  the  nerve  elements  is  the  same. 
Hence  we  sometimes  meet  with  insanity,  usually  of 
a  very  intractable  type,  after  severe  haemorrhage ; 
and  in  all  exhausting  disease  there  is  some  deteriora- 
tion of  mind — deterioration  which,  in  persons  whose 
nervous  system  was  originally  badly  organised,  may 
attain  to  actual  insanity. 

More  potent  even  than  attenuation  of  the  nutritive 
supply  to  the  brain  is  its  vitiation.  By  introducing 
a  poison  into  the  blood,  we  can  produce  insanity  at 
will.  We  can  regulate  the  degree  of  the  insanity  by 
the  amount  of  poison  that  we  administer,  and  we 
can  maintain  the  insanity  as  long  as  we  please  by 
continuing  the  administration  of  the  poison.  Proof 
of  these  statements  is  exhibited  by  every  case  of  drunken- 
ness, b}^  every  case  in  which  chloroform  or  ether  is 
administered.  The  insanity  of  acute  alcoholic  poison- 
ing is  extremely  instructive.  From  it  we  learn  that 
the  rapid  administration  of  a  very  large  dose  of  the 
poison  will  produce  rapid  death  by  coma  ;  that  the 
rapid  administration  of  a  smaller  dose  will  produce  a 
madness  of  short  duration,  passing,  in  a  few  hours, 
through  coma  into  recovery  ;  that  a  more  gradual 
administration  of  several  smaller  doses,  extending 
over  some  hours,  will  produce  an  exalted  delirium  of 


ALCOHOL  AND  INSANITY  11 

a  milder  type,  passing  presently  into  sleep,  and  so  to 
recovery  ;  that  in  those  who  have  been  accustomed  to 
take  alcohol  in  great  excess,  the  sudden  deprivation  of 
alcohol  will  produce  an  attack  of  acute  insanity  of 
very  different  form,  characterised  neither  by  maniacal 
fury  nor  by  jovial  exaltation,  but  by  suspicion,  misery, 
and  prominent  hallucinations  of  vision,  a  form  of 
insanity  which  is  of  longer  duration  than  the  others, 
and  lasts  for  several  days  ;  and,  lastly,  that  the  ad- 
ministration of  alcohol  prolonged  for  years,  will  give 
rise  to  yet  another  kind  of  insanity,  a  kind  in  which 
the  exaltation  of  the  third  phase  is  often  combined 
with  the  suspicion  of  the  fourth,  and  to  them  are 
added  pronounced  defects  of  intelligence,  and  especially 
of  memory,  and.  in  this  form  the  duration  is  still  further 
prolonged.  It  lasts  for  months  and  years,  and  is  often 
irrecoverable. 

The  different  efiects  of  different  dosage,  and  of 
greater  or  less  prolongation  of  the  administration  of 
the  poison,  are  not  all  that  we  learn  from  the  adminis- 
tration of  alcohol.  We  learn  also  that  the  manner  in 
which  the  insanity  is  manifested  depends  not  only 
on  the  dosage  and  the  mode  of  administration,  but 
upon  the  nature  of  the  person  to  whom  the  poison 
is  administered.  One  person  becomes  hilarious,  jovial, 
and  braggart  in  his  cups  ;  another  becomes  sentimental, 
maudlin,  and  confidential ;  a  third  becomes  suspicious 
and  morose  ;  a  fourth  is  cantanl^erous  and  quarrel- 
some, a  fifth  merely  stupid,  and  a  sixth,  under  the  same 
administration  of  the  same  amount,  becomes  furiously 
maniacal,  violent,  and  destructive. 

Alcohol  is  very  important,  because  it  is  not  only 
one  of  the  most  frequent,  but  the  most  manageable, 
p^  all  the  poisons  which  produce  insanity.    The  number 


12  A  TEXT-BOOK  OF  INSANITY 

of  these  poisons  is  very  large,  and  their  constitution 
most  diverse.  They  include  such  simple  substances  as 
carbonic  acid,  whose  intoxicating  effect  is  seen  in  the 
delirium  of  heart  disease,  and  perhaps  in  that  of  pneu- 
monia, and  substances  so  complex  as  the  toxins  produced 
by  the  specific  organisms  of  zymotic  disease.  They 
include  foreign  substances  introduced  into  the  body 
from  without,  as  well  as  toxins  produced  within  the 
body  by  variation  of  its  own  metabolism,  and,  perhaps 
most  deadly  of  all,  toxins  produced  by  invading 
microbes.  Seeing  how  readily  and  how  frequently 
insanity  is  produced  by  the  administration  of  alcohol, 
and  how  very  familiar  we  are  with  the  delirium  of 
fevers,  a  form  of  insanity  that  has  for  many  years  been 
recognised  as  due  to  the  action  of  poisons,  it  is  a  little 
surprising  that  the  influence  of  poisons  in  producing 
insanity  has  only  recently  had  its  due  importance 
assigned  to  it ;  but  it  is  not  at  all  surprising  that  as 
soon  as  the  toxic  origin  of  insanity  is  fully  recognised 
it  should  be  exaggerated,  and  that  the  claim  should  be 
made  that  every  case  of  insanity  is  of  toxic  origin.  This 
is  certainly  not  the  case  ;  but  still,  the  part  of  blood- 
poisoning  in  producing  insanity  is  a  very  important 
one.  It  is  probable  that  it  accounts  for  all,  or  nearly 
all,  cases  of  acute  insanity  ;  and  it  is  now  certain  that 
it  has  a  very  large  share  in  the  production  of  general 
paralysis  of  the  insane.  The  nature  and  mode  of 
origin  of  the  poison  are  often  very  obscure.  It  is 
no  doubt  often  produced  within  the  body  by  some 
fatal  variation  of  its  own  chemistry,  while  often  it 
is  introduced  from  without.  Disease  that  is  due  to 
poisoning,  whether  the  poison  is  introduced  into  the 
body  or  produced  within  it,  is  usually  febrile  in  character; 
it  is  usually  accompanied  by  raised  temperature  and 


INSOMNIA  AND  INSANITY  13 

other  signs  of  fever  ;  but  the  poisons  that  produce 
insanity  do  not  usually  produce  fever.  In  the  delirium 
of  zymotic  disease  there  is,  of  course,  fever.  There  is 
fever  in  acute  delirious  mania,  which  is  probably  a 
disease  of  the  same  class.  In  some  cases  of  puerperal 
insanity  there  is  fever  from  absorption  of  the  decom- 
posing contents  of  the  uterus  ;  but  in  the  great  majority 
of  cases  of  acute  insanity,  which  are  in  my  opinion  due 
to  intoxication,  the  temperature  is  not  raised.  This 
is  a  very  important  clinical  observation,  for  occasionally 
the  invasion  of  zymotic  disease — of  smallpox,  scarlet 
fever,  typhoid  or  other  fever — is  marked  by  an  outbreak 
of  acute  delirium  which  is  indistinguishable  from  the 
acute  insanity  due  to  other  toxins,  except  by  the 
temperature.  A  raised  temperature  in  acute  insanity 
should,  therefore,  always  arouse  suspicion  of  zymotic 
disease.  ^ 

This  is  the  most  appropriate  place  in  which  to  enu- 
merate sleeplessness  among  the  provocations  of  insanity. 
As  with  several  other  factors  in  the  malady,  it  is  difiB.- 
cult  to  determine  how  far  it  acts  as  a  cause  and  how 
far  it  is  a  symptom  merely.  That  there  are  very  many 
persons  who  habitually  sleep  very  badly — lightly, 
intermittently,  and  for  an  insufi&cient  number  of  hours 
— and  who  yet  never  come  within  measurable  distance 
of  insanity,  is  certain.  Equally  certain  is  it  that  acute 
insanity  is  often  preceded  for  days  or  weeks  by  a  great 
and  unusual  degree  of  insomnia,  and  that  the  induction 
of  sleep  often  marks  the  first  step  toward  recovery  ; 
but  whether  the  sleeplessness  is  a  cause  or  a  sign  of  the 
oncoming  insanity  is  uncertain ;  nor  is  it  very  im- 
portant, since  in  either  case  it  is  a  warning,  and  in 
either  case  it  is  to  be  dealt  with  in  the  same  way. 

The  indirect  stresses  that  tend  to  produce  insanity 


14  A  TEXT-BOOK  OF  INSANITY 

are  of  two  kinds — those  which  arise  within  the  limits 
of  the  organism,  and  those  which  arise  in  the  com- 
merce between  the  individual  and  his  circumstances. 

In  the  first  class  are  included  all  those  bodily  pro- 
cesses which  make  large  draughts  upon  the  stored 
energy  of  the  nervous  system,  whether  the  demand 
is  made  by  the  process  of  growth  and  development, 
by  that  of  reproduction,  by  bodily  or  mental  exertion, 
by  the  processes  of  disease,  or  for  recuperation  after 
illness.  Any  process,  in  short,  that  is  generally  ex- 
hausting, may  contribute  to  the  production  of  in- 
sanity, and  a  fortiori  the  concurrence  of  two  or  more  of 
these  processes  is  eminently  provocative  of  insanity. 

Close  observers  of  the  development  of  children  know 
that  their  mental  development  proceeds,  on  the  whole, 
alternately  with  their  bodily  development ;  that  they 
have  periods  in  which  their  bodily  growth  is  stationary, 
while  their  minds  develop  apace,  alternating  with 
periods  in  which  their  bodily  growth  is  rapid  and 
their  mental  development  ceases,  or  seems  even  to 
retrograde.  If,  during  the  latter  period,  an  injudicious 
attempt  is  made  to  force  the  mental  development  by 
close  application  to  mental  work,  the  consequence  will 
be  a  serious  "  nervous  breakdown  "  of  the  nature  of 
insanity.  The  demand  upon  the  energy  of  the  brain 
is  greater  than  it  can  supply  ;  it  becomes  so  depleted 
that  it  cannot  carry  on  its  current  function,  and  the 
depletion  exhibits  itself  in  some  form  of  insanity. 
The  same  condition  may  result,  though  more  rarely, 
from  excessive  addiction  to  athleticism  when  the  mental 
development  is  very  active.  If  the  combined  effect  of 
concurrent  physical  and  mental  development  is  ex- 
haustive, still  more  exhaustive  is  the  additional  demand 
upon  the  energies  of  the  organism  which  is  made  by  the 


REPRODUCTION  AND  INSANITY         15 

evolution  of  the  reproductive  function  at  puberty,  and 
when  to  this  is  added  the  further  drain  of  frequent 
masturbation,  we  can  understand  how  it  is  that  insanity, 
or  a  minor  disorder  of  the  same  nature,  is  so  frequent 
in  adolescence,  and  how  it  is  that  that  is  the  period  of 
life  when  stupor  and  hysteria  are  most  frequent. 

The  dominant  role  of  the  reproductive  function  in 
the  life  of  every  organism  will  be  pointed  out  in  sub- 
sequent chapters.  It  has  now  to  be  noted  that  not 
only  is  reproduction  the  aim  and  end  to  which  all 
life  is  subservient,  but  that  reproduction  and  life  are 
mutually  antagonistic — that  is  to  say,  the  full  and 
complete  life- worthiness  of  the  individual  is  incom- 
patible with  reproduction  ;  and  reproduction  diminishes 
the  life-worthiness  of  the  parent  so  as  in  some  cases 
to  destroy  him  or  her  altogether  ;  and  in  all  cases  to 
render  the  parent,  for  a  time  at  any  rate,  less  capable 
of  living,  less  apt  and  less  competent  to  maintain  the 
struggle  for  existence.  Seeing  that  the  motive  of 
existence  is  the  reproduction  of  the  race,  it  is  to  be 
expected  that,  when  this  aim  is  attained,  existence 
should  cease,  or  at  any  rate  should  approximate  to 
its  close. 

In  the  first  place,  the  addition  of  the  reproductive 
function  to  the  powers  of  the  previously  unproductive 
organism  is  itself  an  occasion  of  disorder.  The  infertile 
organism  consists  of  a  large  number  of  organs  and 
functions  co-ordinated  together  and  acting  one  with 
another  in  due  correlation  as  one  harmonious  whole. 
When  a  new  set  of  organs  and  functions  of  dominant 
importance  has  to  be  added  to  those  already  in  existence, 
has  to  be  correlated  with  them,  to  be  assigned  their 
place  in  the  economy,  and  to  be  allotted  their  share  in 
the  life,  of  the  organism,  it  is  evident  that  so  far-reaching 


16  A  TEXT-BOOK  OF  INSANITY 

and  delicate  a  process  of  equilibration  will  be  very  apt 
to  fail  in  exactitude,  especially  if  the  great  co-ordinating 
agent,  the  brain,  is  lacking  in  power.  Hence  the  period 
of  the  assumption  of  the  reproductive  function  is  always 
a  period  of  danger,  and  very  frequently  of  disorder.  The 
liability  to  disorder  is,  in  the  early  stage  of  the  assump- 
tion, but  small,  and  insanity  at  puberty  is  rare  ;  but 
the  reproductive  function  is  not  then  fully  acquired. 
It  is  not  until  after  seventeen  that  the  female  is  fully 
nubile,  not  until  after  twenty  that  the  male  is  fully 
virile,  and  it  is  not  until  these  ages  that  the  incidence 
of  insanity  becomes  serious.  It  is  then  only  that  the 
individual  becomes,  not  merely  capable  physiologically 
of  continuing  the  species,  but  awake  to  the  responsi- 
bilities of  life.  It  is  then  only  that  the  real  dangerous 
stress  begins  to  bear  upon  the  highest  regions  of  the 
brain  ;  and  while  insanity  before  these  ages  is  rare,  it 
then  begins  to  be  frequent. 

The  reproductive  act  is  a  great  exhauster  of  energy. 
It  is  always  and  of  necessity  inimical  to  life.  In  many 
of  the  lower  animals  it  is  if  so  facto  destructive  of  life. 
In  man,  while  it  is  not  thus  necessarily  fatal,  it  is 
yet  detrimental.  It  is  exhaustive ;  it  renders  the 
organism  less  fit  and  less  capable  of  resisting  adverse 
circumstances ;  and,  if  it  is  repeated  with  undue 
frequency,  its  ill- effects  become  conspicuous.  The 
woman  who  has  children  in  rapid  succession  becomes 
enfeebled,  anaemic,  hysterical,  the  prey  of  neuralgia 
and  of  many  nervous  maladies,  an  easy  victim  to 
tubercle  and  other  bacilli.  The  man  who  repeats 
the  sexual  act  with  great  frequency  becomes  similarly 
etiolated  and  enfeebled  ;  and  both  are  apt  to  give 
evidence  of  the  exhaustion  of  energy  in  neurasthenia 
or  in  insanity.    The  connection  of  masturbation  with 


MASTURBATION  AND  INSANITY  17 

insanity  is  very  close.    A  few  years  ago  masturbation 
was  looked  upon,  it  is  scarcely  too  mucli  to  say,  as 
the  most  potent  cause  and  the  invariable  accompani- 
ment of  insanity  ;   but  nowadays  masturbation  is  not 
regarded  as  the  prime  and  sole  cause  of  insanity.     I 
may  take  some  credit  for  exploding  a  belief  which  was 
once  universal.    In  males,  and  especially  in  unmarried 
adolescent  males,   occasional  masturbation  is   so   ex- 
tremely common  that  it  is  scarcely  to  be  considered 
abnormal.     The  same  is  true  of  older  men  who  have 
no   opportunity  for   the  normal   gratification  of  the 
sexual  passion.    And  by  those  who  are  becoming  insane, 
or  are  liable  to  become  insane,  it  is  no  doubt  practised 
more  freely,  it  may  be  to  great  excess.    But  insanity 
does  not  occur  in  people  who  are  of  sound  mental 
constitution.     It  does  not,  like  smallpox  and  malaria, 
attack  indifierently  the  weak  and  the  strong.    It  occurs 
chiefly  in  those  whose  mental  constitution  is  originally 
defective,  and  whose  defect  is  manifested  in  lack  of 
the  power  of  seK-control  and  of  forgoing  immediate 
indulgence ;    and   when   it   attacks   those   who   were 
originally  normally  constituted,  the  breaking  down  of 
the  power  of  self-control  is  among  its  first  efiects.    It 
would  be  wonderful,  therefore,  if  masturbation  were 
not  practised,  and  practised  freely,  by  those  who  are 
liable  to  become,  or  are  becoming,  insane.    And  since 
the  sexual  act  is  in  all  cases  a  very  efficient  cause  of 
exhaustion  and  depletion  of  energy,  it  cannot  fail  to 
assist  the  deteriorative  process,  to  hasten  the  onset 
of  insanity  where  this  is  impending,  and  to  retard  and 
impede  recovery  where  insanity  is  established.     But 
to  look  upon  masturbation  as  the  sole,  or  even  the 
chief,  agent  in  the  production  of  insanity  is  to  take  a 
very  exaggerated  view. 


18  A  TEXT-BOOK  OF  INSANITY 

In  the  female,  indulgence  in  this  vice  is  very  much 
less  common  than  in  the  male,  and  the  mere  fact  that 
it  is  practised  is  'prima  jade  evidence  that  the  girl 
or  the  woman  who  indulges  in  it  has  not  attained 
to  the  normal  standard,  but  is  congenitally  abnormal. 
In  the  female,  however,  the  sexual  act  is  less  exhausting 
than  in  the  male,  and  while  the  significance  of  mastur- 
bation as  an  indication  of  an  abnormal  mental  constitu- 
tion is  greater,  its  importance  as  a  contributory  cause 
of  insanity  is  much  less. 

While  the  female  is  less  obnoxious  to  the  deteriora- 
tive influence  of  masturbation  than  in  the  male,  she 
is  liable  to  other  stresses  of  reproduction  from  which 
he  is  exempt.  Upon  her  fall  the  stresses  of  pregnancy, 
parturition,  and  lactation,  each  of  which  may  be  the 
occasion  of  insanity.  The  "  longings,"  and  equally 
the  aversions,  of  the  pregnant  woman  are  aberrations 
of  mind  so  usual  that  they  scarcely  attract  attention ; 
but  any  occasion  on  which  disorder  of  mind,  however 
trifling,  occurs  in  healthy  and  well-constituted  people 
is  an  occasion  on  which  insanity  may  occur  in  those 
who  are  less  healthy  and  less  well  constituted.  Indeed, 
considering  how  considerable  are  the  mental  disorders 
that  often  accompany  pregnancy,  the  aversion  to  the 
husband,  the  excessive  caprice,  the  restlessness  and 
*'  nervousness,"  it  is  remarkable  that  insanity  is  not 
more  frequent  in  pregnancy,  for  on  the  whole  it  is  an 
infrequent  occasion  of  insanity,  only  about  one  per 
cent,  of  all  the  cases  of  insanity  that  occur  in  women 
being  associated  with  this  condition. 

The  puerperal  state  is  a  much  more  frequent  occasion 
of  insanity,  about  six  per  cent,  of  all  the  cases  among 
women  occurring  in  connection  with  childbirth — that 
is  to  say,  within  a  month  or  so  of  parturition — and 


CHILDBIRTH  AND  INSANITY  19 

when  we  consider  all  that  childbirth  implies,  we  find 
no  cause  for  surprise  that  this  should  be  so.    In  the  first 
place,  when  the  child  is  born,  an  immense  readjustment 
of  physiological  processes  has  to  be  made  in  the  maternal 
organism.     The   great   supply   of   pabulum  that  has 
hitherto  been  made  to  the  uterus  is  now  no  longer 
needed  there,  can  now  no  longer  be  dealt  with  there, 
and  has  in  part  to  be  drafted  ofi  to  the  breasts,  in  part 
to  be  dispensed  with.    The  continual  stream  of  efiete 
products  from  the  nutrition  of  the  foetus  is  suddenly 
cut  off,  all  the  arrangements  for  dealing  with  them  are 
deprived  of  their  material  from  this  source.    No  doubt 
the  rapid  involution  of  the  uterus  supplies  their  place 
in  so  far  as  quantity  goes,  but  the  quality  is  probably 
very    different,    and    needs    further    readjustment    of 
excretory  processes  to  enable  it  to  be  dealt  with.    Then 
the  process  of  labour  is  itself  a  very  severe  drain  upon 
the  great  reservoir  of  bodily  energy,  and  thus  diminishes 
its  capacity  to  bring  about  these  adjustments  just  at 
the  time  when  they  are  needed.    In  addition  to  this,  the 
haemorrhage,  frequently  excessive,  is  of  itself  a  cause 
of  serious  stress  ;    and  when  to  all  these  stresses  is 
added  the  absorption  of  septic  matter  from  the  decom- 
posing contents  of  the  uterus,  the  wonder  is,  not  that 
puerperal  insanity  is  frequent,  but  that  it  is  not  much 
more  frequent.     In  a  certain  proportion  of  cases  of 
puerperal  insanity,  about  one-fourth,  the  temperature 
is  raised,  and  in  these  cases  the  suspicion  that  the 
insanity  is  dependent  upon  sepsis  is  often  confirmed  by 
the  result  of  local  measures  directed  to  emptying  the 
uterus    of    decomposing    matter    and    sweetening    its 
contents.    But  on  the  one  hand,  the  adoption  of  these 
measures  in  such  cases  does  not  always  produce  im- 
provement in  the  insanity,  showing  that  even  where  the 


20  A  TEXT-BOOK  OF  INSANITY 

temperature  is  raised,  the  origin  of  the  insanity  is  not 
wholly  septic  ;  and  on  the  other,  we  know  that  there 
are  poisons  which  produce  insanity  without  raising  the 
temperature,  so  that  we  cannot  be  sure  that  where  the 
insanity  is  not  septic  it  is  not  toxic. 

Puerperal  insanity  is  most  frequent  in  the  first 
fortnight  after  labour,  and  when  more  than  a  month 
has  elapsed  before  the  outbreak,  it  is  no  longer  called 
puerperal.  At  this  period  insanity  is  infrequent,  and 
it  is  not  until  the  later  months  of  lactation  that  the 
liability  again  increases.  The  insanity  of  lactation  is 
a  disease  of  exhaustion.  It  occurs  in  women  who 
have  suckled  long  and  freely,  who  have  had  insufficient 
food,  and  who  have  perhaps  had  to  work  hard  ever 
since  they  rose  prematurely  from  their  lying-in.  It  is 
therefore  much  more  frequent  among  poor  women 
than  among  the  well-to-do. 

The  climacteric  is  another  of  those  periods  of  physio- 
logical adjustment  which  make  so  severe  a  call  upon 
the  powers  of  the  highest  co-ordinating  organ.  The 
deprivation  of  function,  no  more  than  the  addition 
of  function,  can  be  effected  without  disturbing  the 
general  balance  among  the  various  functions  of  the 
body.  This  balance  has  to  be  readjusted,  and  the 
equilibration  is  sometimes  beyond  the  power  of  the 
organism  to  effect,  and  the  result  is  disorder  of  the 
highest  nerve  regions  on  which  the  strain  falls.  The 
climacteric  period  is  always  a  period  of  some  disorder 
in  women.  They  are  troubled  with  sleeplessness, 
irritability  of  temper,  despondency,  loss  of  energy,  and 
lackadaisicalness ;  and  in  exceptional  cases  these 
aberrations  are  exaggerated  into  actual  insanity.  A 
similar  affliction  may  occur  in  men  at  about  the  age  of 
sixty,  which  is  sometimes  attributed  to  a  climacteric 


BODILY  DISEASE  AND  INSANITY         21 

in  them,  though  it  is  more  usually  associated  with  the 
total  change  of  habits  and  loss  of  interests  arising  from 
retirement  from  business. 

The  other  stresses  of  this  class  are  those  which  arise 
from  bodily  disease.  In  these  cases  the  stress  no  doubt 
very  often  belongs  to  the  previous  class,  and  is  a  poison 
produced  by  the  morbid  process,  or  perhaps,  as  in  the 
case  of  myxoedema,  a  poison  not  so  much  produced  as 
permitted.  The  poison  is  not  actually  produced  by 
the  morbid  process,  but  owing  to  this  process,  it  is  no 
longer  neutralised,  and  so  produces  its  efiect.  Generally 
it  may  be  stated  that  every  bodily  disease  has  its  effect 
upon  the  sanity,  even  if  it  is  only,  by  diminishing  the 
full  efficiency  of  the  cerebral  action,  to  produce  a  mild 
and  inconspicuous  weakening  of  the  mental  power  ; 
and  in  many  cases  of  bodily  disease  the  disorder  of  the 
cerebral  processes  is  considerable  enough  to  amount 
to  actual  insanity,  as  the  frequency  of  delirium  shows 
us.  In  the  majority  of  cases,  such  insanity  may  be 
attributed  either  to  starvation,  or  to  poisoning  of  the 
convolutions  ;  in  some  cases  these  two  causes  co-operate, 
as  in  bronchitis,  asthma,  and  heart  disease  ;  in  some 
cases  we  trace  the  origin  of  the  insanity  to  exhaustion 
of  the  cerebral  energy,  as  in  epilepsy  ;  and  in  others  we 
are  unable  to  offer  a  probable  explanation  of  the  mode 
in  which  the  insanity  is  brought  about.  Among  the 
starvation  insanities  may  be  instanced  those  which 
occasionally  occur  in  anaemia  and  chlorosis,  and  post- 
febrile insanity,  as  well  as  that  weakening  of  mental 
power  which  is  observable  in  every  illness  of  long 
standing — a  weakening  which  often  escapes  notice, 
since  persons  so  situated  are  not  often  called  upon 
for  severe  intellectual  effort.  Among  the  insanities 
due  to  poisoning  may  be  instanced  those  which  occur 


22  A  TEXT-BOOK  OF  INSANITY 

in  Blight's  disease,  in  gout,  in  lead  poisoning,  in  diabetes, 
as  well  as  the  delirium  of  fever,  and  perhaps  also  the 
gloom,  often  deepening  into  melancholy,  of  chronic 
dyspepsia  and  intestinal  torpor. 

Bodily  disease  is  often  connected  causally  with 
insanity  in  the  sense  that  the  bodily  malady  supplies 
the  localisation,  as  it  were,  of  the  delusions  which  are 
part  of  the  insanity.  Tinnitus  aurium  supplies  the 
provocation  for  aural  hallucinations  ;  intestinal  ulcer 
co-exists  with  the  delusion  that  the  bowels  are  ob- 
structed ;  chronic  dyspepsia  may  suggest  that  there 
is  a  live  weasel  or  lobster  in  the  stomach  ;  some  uterine 
affection  may  be  at  the  root  of  a  delusion  of  pregnancy  ; 
some  vaginal  irritation  may  so  direct  the  delusion  that 
the  patient  believes  she  is  frequently  raped,  and  so  forth. 

Lastly,  as  old  age  comes  on,  it  may  be  attended, 
not  by  a  gradual  and  equable  decline  of  the  faculties, 
but  by  a  breakdown  more  or  less  catastrophic  in 
character,  which  may  take  the  form  of  depression, 
of  excitement,  of  persistent  delusions,  of  rapid  dementia, 
or  of  several  other  forms  of  insanity. 

Stresses  of  the  third  class  are  those  which  arise  out 
of  the  relations  between  the  organism  and  its  sur- 
roundings, and  may  be  dealt  with  in  the  order  proposed 
for  the  activities  of  conduct  in  the  next  chapter.  The 
circumstances  under  which  these  stresses  arise  are  those 
which  arouse  emotion,  and  the  more  powerful  the 
emotion  aroused,  and  the  greater  the  suddenness  with 
which  it  is  aroused,  the  more  effectual  is  the  stress  in 
producing  insanity.  Stresses  of  this  class  are,  upon  the 
whole,  much  less  potent  than  those  of  internal  origin, 
which  in  their  turn  are  less  effectual  than  those  which 
have  been  termed  direct.  The  stresses  with  which  we 
are  now  dealing  do  not  produce  insanity  except  in  those 


INDIRECT  STRESSES  23 

who  are  already  predisposed  to  become  insane  by  tbeir 
heredity. 

In  the  relations  which  directly  concern  the  physical 
safety  of  the  organism,  the  only  circumstances  that 
are  capable  of  provoking  insanity  are  those  of  fright, 
or  "  nervous  shock."  The  stress  is  not  a  fertile  cause 
of  insanity,  but  a  certain  small  proportion,  about  one 
per  cent,  of  all  the  cases  that  come  under  treatment, 
are  assigned  to  this  cause. 

Stresses  arising  in  the  circumstances  under  which 
the  livelihood  is  earned  are  more  important.  It  does 
not  appear  that  extreme  poverty  is  of  itself  provocative 
of  insanity,  for  we  do  not  find  that  it  is  very  prevalent 
among  those  who  live  in  penury,  nor  among  the  victims 
of  what  is  known  as  the  "  sweating  system."  But  the 
apprehension  of  poverty,  the  fear  of  losing  the  means 
of  livelihood,  and  the  descent  from  more  prosperous  to 
less  prosperous  circumstances,  are  very  efficient  occa- 
sions of  insanity  among  those  who  are  already  predis- 
posed by  constitution  to  become  insane.  In  about 
five  and  a  half  per  cent.,  or  nearly  as  large  a  proportion 
as  can  be  assigned  among  women  to  parturition,  in- 
sanity is  traceable  to  the  stress  of  difficulty  in  main- 
taining the  standard  of  living. 

Among  the  circumstances  which  have  a  certain 
efficiency  in  occasioning  insanity  is  change  in  the 
mode  of  livelihood.  \\Tien  a  man  gives  up  one  career, 
and  embarks  upon  another,  when  a  medical  man  turns 
journalist,  or  a  solicitor  is  called  to  the  Bar,  the  revolu- 
tion in  the  mode  of  life,  added  to  the  anxiety  as  to  the 
success  of  the  venture,  is  occasionally  a  source  of 
insanity  ;  and  the  complete  revolution  of  habit  involved 
in  retirement  from  business  when  mind  and  body  are 
still  active,  and  no  provision  has  been  made  for  their 


24  A  TEXT-BOOK  OF  INSANITY 

employment  in  other  directions,  is  also  an  occasional 
source  of  disorder.  The  form  that  the  insanity  takes 
in  such  cases  is  usually  that  of  depression  with  delusions 
of  poverty. 

Stresses  arising  in  connection  with  the  family  cir- 
cumstances are  a  frequent  source  of  disorder  amount- 
ing to  insanity.  First  in  order  among  these  come 
disappointments  in  love  and  other  troubles  arising  in 
the  course  of  courtship,  which  account  for  about  one 
per  cent,  of  the  occurring  cases  of  insanity.  Now  and 
then  the  circumstance  of  becoming  engaged  to  be 
married  will  so  agitate  a  nervous  girl  as  to  render  her 
actually  insane  ;  and  if  this  occurs  upon  engagement 
only,  a  fortiori  it  may  occur  upon  the  occasion  of 
marriage.  There  are  innocent  girls  who  are  totally 
ignorant  of  what  marriage  implies  ;  who  are  coerced 
into  marriage  with  men  for  whom  they  have  no  affection, 
whom  perhaps  they  positively  dislike  ;  and  who  learn 
for  the  first  time  on  their  wedding  night  what  marriage 
really  means.  Such  cases  are  rare,  no  doubt,  but 
they  actually  occur,  and  are  responsible  for  a  very 
small  number  of  cases  of  insanity.  As  few  are  the 
cases  in  which  connubial  excess  produces  insanity  in 
the  husband,  but  such  cases  also  occasionally  present 
themselves. 

No  case  has  been  recorded,  so  far  as  I  am  aware, 
of  extreme  unhappiness  in  married  life  being  provoca- 
tive of  insanity,  although  it  would  seem  a  priori  as 
if  few  stresses  of  the  order  that  we  are  dealing  with 
could  be  more  severe.  Cases  have  occurred,  however, 
in  which  the  discovery  of  the  unfaithfulness  of  a  wife 
has  been  followed  by  her  insanity,  and  other  cases  in 
which  it  has  been  followed  by  the  insanity  of  the  injured 
husband. 


SOCIAL  STRESSES  25 

The  parental  relationship  is  full  of  occasions  of 
anxiety,  which  are  stresses  that  may  contribute  to 
the  production  of  insanity.  Anxiety  over  the  illness  of 
children,  the  strain  and  exhaustion  of  nursing  them, 
the  grief  over  their  profligacy  or  crime,  worries  as  to 
the  means  of  supporting  them,  are  all  stresses  which 
help  to  produce  insanity  in  parents  who  are  not  by 
nature  constituted  to  withstand  exhausting  emotions. 

The  stresses  that  arise  out  of  the  social  relations 
are  not  often  sufficiently  severe  to  provoke  insanity, 
but  sometimes  they  have  this  effect.  Man  is  a  gregarious 
animal,  and  cannot  live  a  healthy  life  in  solitude.  If 
he  is  compelled  to  live  alone,  there  is  much  danger  to 
his  mental  health,  and  even  if  he  does  not  live  alone, 
but  his  social  circle  is  greatly  restricted,  the  integrity  of 
the  mind  suffers.  People  who  live  in  a  very  narrow 
social  environment,  especially  if  their  time  is  insuffi- 
ciently occupied  and  their  interests  are  restricted,  are 
extremely  apt  to  exhibit  morbid  traits  of  mind  and 
conduct.  They  attach  a  monstrous  consequence  to 
trifles  ;  they  become  fretful,  irritable,  and  quarrelsome  ; 
and  they  are  extremely  apt  to  take  to  drink.  Drink  is 
the  curse  of  small  communities.  Prisoners  who  are 
kept  in  solitary  confinement  have  often  become  insane, 
and  although  the  causative  influence  of  the  solitude  has 
been  repeatedly  denied,  no  one  who  has  been  deprived 
of  congenial  companionship  for  long  stretches  of  time 
can  doubt  that  the  deprivation  has  a  serious  effect  upon 
the  mental  health.  When,  as  in  the  case  of  many 
criminals,  the  man  who  is  subjected  to  the  deprivation 
is  originally  a  feeble  being  without  mental  resources, 
its  effect  is  necessarily  more  severe  ;  and,  in  practice, 
solitary  confinement  for  long  periods  has  been  in  most 
civilised  countries  abandoned. 


26  A  TEXT-BOOK  OF  INSANITY 

Not  only  is  companionsliip  of  his  fellows  necessary 
to  the  mental  health  of  man,  but  it  is  of  prime  necessity 
that  he  should  secure  their  good  opinion  ;  and  the 
loss  of  esteem,  the  knowledge  that  he  is  reprobated 
and  held  in  contempt  and  aversion,  is  a  stress  of  so 
severe  a  character  that  we  might  expect  to  find  it  a 
frequent  occasion  of  the  onset  of  insanity.  In  practice, 
however,  we  do  not  find  it  so.  The  Jabez  Balfours  and 
Benjamin  Lakes  do  not  appear  to  be  more  prone  to 
insanity  than  are  other  criminals  ;  and  the  reason  may 
be  that  they  are  secluded  from  all  actual  experience 
of  the  expression  of  this  reprobation,  and  find  themselves 
but  units  among  a  crowd  of  others  who  are  similarly 
treated. 

The  religious  circumstances  in  which  a  person  lives 
have  not,  at  any  rate  nowadays,  much  influence  upon 
his  sanity.  The  tumultuous  emotional  experiences  of 
a  "  revival,"  as  it  is  termed,  do,  not  infrequently,  upset 
the  mental  equilibrium  of  the  feebler  folk  ;  and  we  hear 
of  their  falling  in  trances  and  being  subject  to  con- 
vulsions under  the  influence  of  the  minatory  preaching 
of  some  eloquent  enthusiast,  and  cases  undoubtedly 
occur  in  which  such  experiences  are  provocative  of 
insanity  in  persons  previously  disposed  to  become 
insane  ;  but,  in  this  country  at  least,  the  number  of 
such  cases  is  insignificantly  small. 


CHAPTER   II 


CONDUCT 


Conduct  is  the  pursuit  of  ends  ;  and  an  investigation 
into  the  several  activities  that  together  constitute 
conduct  resolves  itself  into  an  analysis  of  the  ends 
which  mankind  pursue,  and  the  apportionment  to  each 
of  its  relative  importance. 

The  outcome  of  the  stupendous  biological  discoveries 
of  the  latter  half  of  the  last  century  is  to  show  that 
all  life  is  teleological,  and  that  the  great  and  ultimate 
end  to  which  all  life  is  directed,  towards  which  every 
living  being  strives,  for  which  every  living  being  exists, 
and  to  which  all  other  ends  are  but  means,  is  the  con- 
tinuation of  the  race  to  which  the  individual  belongs. 
To  each  individual,  life  is  not  a  gift  but  a  trust,  to  be 
employed  in  transmitting  life  to  a  new  generation ; 
and,  this  purpose  effected,  the  reason  for  the  existence  of 
the  individual  is  at  an  end.  This  is  very  clearly  indicated 
in  the  lives  of  many  of  the  lower  animals,  in  which  re- 
production is  followed  at  once  by  death.  Hence  the 
whole  scheme  of  existence  centres  around  the  repro- 
ductive function,  and  the  first,  the  greatest,  the  most 
important,  the  most  fundamental  group  of  activities 
of  which  human,  in  common  with  all  other  living, 
beings  are  capable,  consists  of  those  which  directly 
subserve  the  reproductive  function,  activities  which  in 
mankind  begin  with  the  first  approaches  of  courtship, 
and  do  not  cease  until  the  last  child  is  established  in 

27 


28  A  TEXT-BOOK  OF  INSANITY 

the  world,  and  capable,  in  its  turn,  of  handing  on  the 
sacred  fire  of  life  to  a  succeeding  generation. 

Although,  however,  the  reproductive  activities  are 
the  fundamental  activities  and  the  reproductive  instincts 
the  fundamental  instincts  out  of  which  the  whole  vast 
fabric  of  human  conduct  has  grown,  yet  these  are  not 
the  only  activities  of  which  human  beings  are  capable, 
nor  are  these  the  only  desires  they  experience.  We  see 
in  nearly  all  the  lower  animals  that  the  instincts  of 
reproduction,  fundamental  as  they  are,  become  active 
for  short  periods  only  of  their  lives,  and  in  some,  such 
as  worker  bees,  ants,  and  wasps,  the  cruder  desires  are 
altogether  evanescent,  and  have  no  part  in  their  lives. 
In  human  beings  also  the  instinctive  desires  of  reproduc- 
tion only  occasionally  obtain  dominance,  and  in  some 
are  as  evanescent  as  they  are  in  worker  bees.  In  spite 
of  this  very  obvious  fact,  a  new  school  has  recently 
arisen  which  looks  upon  crude  sexual  desire  as  not 
only  the  fundamental  desire,  but  also  the  dominant 
desire,  and  as  not  merely  occasionally  asserting  itself, 
but  as  practically  the  one  only  continuous  desire  which 
dominates  the  whole  of  human  life.  Every  act,  however 
pure  and  remote  from  sexuality,  even  a  day's  shooting 
or  the  keeping  of  a  pet  cat,  is  regarded  by  this  school  as 
the  expression  of  lust,  so  true  it  is  that  to  the  impure  all 
things  are  impure. 

Before  considering  disorder  of  conduct  in  detail,  it 
should  be  noted  that  conduct  of  any  kind  is  susceptible 
of  four  different  kinds  of  disorder,  according  as  the 
instinctive  desire  which  prompts  it  is  excessive,  defective, 
perverted,  or  reversed.  Excess  and  defect  need  no 
explanation,  but  I  must  explain  that  by  perverted 
conduct  I  mean  conduct  which  tends  or  is  calculated  to 
defeat  the  very  instinct  by  which  it  is  prompted.    The 


REPRODUCTIVE  CONDUCT  29 

normal  desire  for  food,  for  instance,  prompts  us  to  eat 
things  that  are  nutritious,  and  therefore  appetising  to 
the  normal  man.  When  the  appetite  for  food  is  per- 
verted, it  prompts  the  consumption  of  substances  like 
coals  or  clay,  that  are  manifestly  innutritions,  and  un- 
appetising to  the  normal  man.  By  reversal  of  instinctive 
desire  I  mean  the  experience  of  a  desire  to  do  the  very 
reverse  of  what  is  prompted  by  the  normal  instinct. 
The  normal  instinct  of  self-preservation  prompts  us 
to  avoid  pain  and  bodily  injury  and  discomfort ;  above 
all  to  avoid  death.  Reversal  of  this  instinct  prompts  to 
self -mutilation  and  suicide.  The  reproductive  activities 
fall  naturally  into  three  groups — those  of  courtship,  of 
reproduction  proper,  and  of  parentage. 

The  activities  of  courtship  need  not  detain  us,  since 
they  are  not  very  important,  and  are  but  little  liable 
to  disorder.  We  witness  in  them,  however,  the  same 
curious  phenomenon  of  reversal  that  we  shall  have  to 
notice  in  the  manifestation  of  other  instincts  ;  that  is 
to  say,  we  witness  conduct  directed,  not  to  the  attain- 
ment, but  to  the  defeat,  of  the  instinctive  end.  We 
see  women,  instead  of  decking  themselves  in  colours 
and  endeavouring  to  make  themselves  attractive  by 
becoming  costume,  assuming  the  trappings  of  a  nun, 
and  adopting  elaborate  devices  to  make  their  appearance 
repellent. 

The  reproductive  function  proper  is  subject  to 
several  morbid  aberrations.  The  commonest  of  these 
is  masturbation,  to  which  a  great  deal  of  factitious 
importance  has  been  ascribed.  There  are  few  diseases 
of  the  nervous  system  whose  causation  has  not  at  one 
time  or  another  been  attributed  to  masturbation,  and, 
in  insanity,  both  the  physician  and  the  patient  are 
accustomed  to  regard  it  as  a  factor  of  the  greatest 


30  A  TEXT-BOOK  OF  INSANITY 

importance.  It  is  probable,  however,  that  its  share  in 
the  production  of  insanity  has  been  much  exaggerated. 
As  far  as  it  is  possible  to  judge,  it  seems  most  likely 
that  very  few  lads  pass  through  the  period  of  adoles- 
cence without  sporadic  and  occasional  indulgence  in 
this  vice  ;  and  it  is  certain  that  in  many  cases  it  is 
practised  with  considerable  regularity  and  frequency 
without  producing  insanity.  There  is  no  doubt  that 
it  is  practised  before  the  outbreak  of  the  insanity  by 
a  considerable  proportion  of  those  who  become  insane, 
and  by  all  who  become  insane  before  the  age  of  twenty- 
five  ;  and  although  it  has  unquestionably  an  influence, 
varying  with  the  person  by  whom,  and  with  the  extent 
to  which,  it  is  practised,  in  precipitating  the  outbreak 
and  increasing  its  severity,  yet  it  is  to  be  regarded 
upon  the  whole  rather  as  a  symptom  than  as  a  cause 
of  insanity  in  such  cases.  The  excess  with  which  it  is 
indulged  in  is  due  to  that  inherent  lack  of  self-control 
which  is  an  inseparable  part  of  insanity,  and  which  is 
so  often  conspicuous  in  its  early  stages. 

Perversion  of  the  sexual  passion,  or  its  direction 
towards  abnormal  objects — towards  the  same  sex,  for 
instance — and  its  gratification  in  abnormal  ways — with 
accompaniments  of  brutality  and  blood-thirstiness — are 
subjects  which  have  of  recent  years  been  treated  by 
certain  writers  with  a  lingering  solicitude  and  a  minute- 
ness of  detail  out  of  all  proportion  to  their  importance. 
It  is  true  that  cases  of  such  perversion  are  not  extremely 
rare,  but  they  are  not  usually  attended  by  any  other 
symptom  of  insanity,  and  the  question  whether  this 
perversion  in  itself  constitutes  insanity  is  one  which 
can  scarcely  be  considered  here  at  length.  It  is  cer- 
tainly not  so  in  law,  and  the  abnormal  gratification  of 
the  sexual  passion  being  a  criminal  ofience,  the  persons 


PABENTAL  CONDUCT  31 

who  are  addicted  to  these  practices  are  convicted  and 
sentenced  as  sane  people  at  every  session  of  the  Central 
Criminal  Court,  excuse  or  mitigation  of  the  offence, 
upon  the  ground  of  the  insanity  of  the  act,  being  un- 
known. 

Disorder  of  parental  conduct  is  not  infrequent. 
Among  the  lowest  class  of  the  population  in  large 
towns  the  obligations  of  paternity  are  frequently 
neglected  or  altogether  ignored  ;  and  the  occasional 
desertions  of  infants  and  young  children  are  instances 
of  defect  in  maternal  conduct,  defects  which  are  some- 
times paralleled  by  parents  in  higher  social  strata. 
Excess  of  parental  solicitude,  to  the  extent  that  the 
health  of  the  parent  is  damaged,  and  even  the  life 
sacrificed,  by  devotion  to  the  offspring,  is  not  very 
uncommon,  but  is  not  a  wide  departure  from  the 
normal,  for  parenthood  of  necessity  implies  self-sacrifice. 
Nor  can  that  diversion  of  the  parental  instinct  which 
leads  an  old  maid  to  lavish  attention  upon  a  pug-dog, 
a  cat,  or  a  canary-bird,  in  the  absence  of  any  more 
appropriate  object,  be  looked  upon  as  abnormal.  There 
are,  however,  perversions  of  the  parental  instinct  which 
evince  manifest  disorder.  Chief  of  these  is  the  rage 
of  destruction,  directed  against  the  new-born  offspring, 
which  is  such  a  frequent  and  terrible  feature  in  the 
insanity  of  child-bed.  It  is  remarkable  that  this  re- 
version of  the  parental  instinct  occurs  in  connection 
with  parturition  among  the  lower  animals  also.  Dogs, 
pigs,  and  rabbits  frequently  kill  and  devour  their  new- 
born offspring  ;  and  ewes  will  often  repel,  and  leave  to 
perish  of  starvation,  the  weaklier  of  their  twin  lambs. 
The  parallelism  does  not  explain  the  occurrence,  how- 
ever, though  no  doubt  it  indicates  the  direction  in 
which  an  explanation  is  to  be  sought,  and  at  present 


32  A  TEXT-BOOK  OF  INSANITY 

this  strange  aberration  of  conduct  remains  inexplic- 
able. 

Next  in  importance  to  the  reproductive  activities 
are  the  directly  self-conservative — those  activities 
whose  performance  is  necessary  to  the  maintenance 
of  life  from  hour  to  hour  and  from  moment  to  moment 
— those  by  which  obvious  physical  dangers  to  life  are 
averted.  These  are  the  activities  by  which  a  person 
avoids  falling  into  pits  ;  collisions  with  moving,  and 
eke  with  stationary,  objects  ;  falling  into  fire  or  water  ; 
drinking  scalding  fluids ;  running  into  dangers  of 
ferocious  or  poisonous  animals  ;  and,  generally,  those 
obvious  dangers  which  prohibit  us  from  leaving  young 
children  without  supervision.  Defect  of  the  activities 
of  this  class  is  presented  by  all  young  children,  and  in 
them  the  defect  is  normal ;  but  when  it  is  prolonged 
beyond  the  stage  of  childhood,  the  defect  is  morbid, 
and  is  characteristic  of  that  class  of  the  insane  that  is 
connoted  by  the  term  "  idiot."  Defect  of  these  activities 
is  not  always  original.  It  may  be  acquired.  While 
idiots  never  attain  to  the  degree  of  intelligence  that 
enables  them  to  guard  themselves  against  these  obvious 
dangers,  there  is  another  large  class  of  the  insane  who 
have  acquired  the  activities  of  this  class  in  full,  but 
who  have  subsequently  lost  them,  and  these  activities 
are  among  the  last  to  be  lost  in  the  deeper  degrees  of 
dementia.  Deeply  demented  persons,  no  more  than 
young  children,  can  safely  be  trusted  to  be  alone.  They 
are  apt  to  fall  downstairs  ;  to  set  their  clothes  on  fire  ; 
to  lie  naked  and  shivering  with  cold,  for  want  of  sense 
enough  to  pull  the  bedclothes  over  them  ;  to  trip  over 
steps,  or  buckets,  or  what  not,  and  fall ;  and  to  incur  in 
other  ways  dangers  that  arise  from  want  of  the  simplest 
care  and  forethought. 


FAULTY  HABITS  33 

Among  these  primitive  modes  of  activity,  which  are 
acquired  at  a  very  early  age  and  are  lost  only  when 
the  later  stages  of  dissolution  are  reached,  is  that 
which  mankind  shares  not  only  with  the  great  majority 
of  mammals  and  birds,  but  with  bees  and  ants  and 
other  social  insects,  of  depositing  his  excrement  at  a 
distance  from  his  habitual  haunts,  and  in  such  a  manner 
that  it  shall  not  soil  his  person  and  render  it  offensive 
to  himself  and  his  fellows.  This  mode  of  conduct  is 
very  often  defective  in  insanity,  and  very  often  affected 
out  of  its  turn,  as  it  were,  and  at  a  much  earlier  stage 
of  dissolution  than  we  should  expect.  It  is  common 
to  find  insane  persons  in  good  physical  health,  capable 
of  acts  of  considerable  elaborateness,  able  not  only  to 
feed  themselves,  to  undress  themselves,  to  converse 
with  some  intelligence,  to  find  their  way  from  place  to 
place  in  their  customary  abodes,  who  yet,  without  any 
paralysis  of  sphincters,  pass  their  water  and  motions 
under  them  as  they  sit  and  lie.  Considering  at  what  a 
very  early  stage  of  development  this  faculty  is  attained, 
it  is  remarkable  that  it  should  so  often  be  lost  long 
before  other  faculties  of  much  later  attainment ;  and 
its  loss  is  very  significant  and  of  very  unfavourable 
import.  Whatever  the  form  of  the  insanity,  an  insane 
person  who  lapses  from  cleanliness  in  this  respect  rarely 
recovers.  Usually  the  first  appearance  of  this  symptom 
marks  the  beginning  of  the  end.  In  acute  cases  it 
very  often  means  that  the  patient  is  going  to  die;  in 
chronic  cases  it  means  that  he  is  settling  into  hopeless 
dementia. 

This  phase  of  conduct  is  susceptible  not  only  of 
defect,  but  of  perversion.  There  are  many  insane 
persons  who  not  only  soil  their  clothes  with  their 
fseces,  but  who  revel  in  paddling  in  their  filth.    They 


34  A  TEXT-BOOK  OF  INSANITY 

wasli  their  hands  in  it ;  they  knead  it ;  they  take  it 
in  their  hands  and  plaster  it  about  the  walls  and  fur- 
niture of  their  rooms,  on  their  persons,  on  their  faces, 
and  in  their  hair.  Such  reversal  of  the  ordinary  normal 
conduct  of  mankind  is  difficult  to  account  for,  but 
though  it  is  not  in  all  cases  explicable,  there  are  many 
in  which  an  explanation  can  be  conjectured.  There 
a.^e  some  lunatics  who  are  so  lazy,  whose  detestation 
of  distasteful  exertion  is  pushed  to  such  an  extreme 
that  they  will  wet  the  bed  from  sheer  dislike  of  the 
trouble  of  getting  out  to  make  water.  Others  there  are 
who  are  possessed  by  an  impish  spirit  of  malignity,  and 
whose  desire  to  give  trouble  and  to  outrage  the  feelings 
of  those  around  them  will  manifest  itself  in  this  way  ; 
and  finally — it  is  an  extraordinary  fact,  but  one  that 
cannot  be  doubted  by  those  who  have  had  much  ex- 
perience of  the  insane — that  in  some  cases  pleasure  of 
a  sexual  character  is  derived  from  these  practices,  and 
they  are  undertaken  with  that  end  in  view. 

The  other  directly  self-conservative  activities  are 
likewise  frequently  perverted,  and  even  reversed. 
Instead  of  conduct  being  directed  to  the  preservation 
of  life  and  the  quest  of  pleasure,  it  is  directed  by  a  fury 
of  self-destruction  and  an  unquenchable  desire  for  the 
self-infliction  of  pain  and  suffering  ;  and  one  of  the 
commonest  of  the  forms  which  is  exhibited  by  the 
perversion  of  the  self-conservative  activities  is  the 
unwillingness,  often  amounting  to  obstinate  refusal, 
to  take  food.  The  refusal  to  eat  may  be  due  to  a  con- 
viction that  all  the  food  is  poisoned,  or  it  may  be 
deliberately  adopted  as  a  suicidal  expedient ;  and 
both  of  these  motives  are  frequent.  But  often  it 
is  exhibited  by  patients  who  have  not  sufficient  in- 
telligence to  form  either  the  hypothesis  or  the  inten- 


SUICIDAL  CONDUCT  35 

tion,  but  in  whom  it  is  part  of  a  brutish  resistiveness 
which  leads  them  to  oppose  every  mode  of  activity 
that  is  proposed  to  them.  They  struggle  against  being 
fed  with  the  same  mulish  obstinacy  that  they  struggle 
against  being  dressed,  against  being  undressed,  against 
being  sat  down  or  stood  up,  against  walking  about, 
against  standing  still,  against  every  form  of  activity 
that  they  are  desired  to  undertake  ;  and  their  struggles 
are  varied  by  endeavours  to  injure  those  who  have 
care  of  them.  The  conduct  that  they  exhibit  reminds 
us,  on  the  one  hand,  of  a  wild  animal  that  resents  its 
capture,  and  on  the  other  of  a  jibbing  horse  ;  and  a 
plausible  explanation  is  to  regard  it  as  a  resuscitation 
of  such  obsolete  instincts  as  these. 

The  craving  for  suicide  and  self-injury  exhibits  itself 
in  many  other  ways  besides  that  of  refusing  food,  and 
perhaps  its  commonest  expression  is  in  a  leap  from  a 
window.  Persons  without  experience  of  insane  people 
usually  consider  that  if  a  window  is  shut  and  fastened 
so  that  it  cannot  be  opened,  the  precaution  against  a 
suicidal  leap  through  it  is  complete  ;  but  a  patient 
who  is  determined  upon  suicide  takes  no  account  of  the 
obstacle  of  a  mere  pane  of  glass,  and  will  jump  through 
a  shut  window  as  readily  as  through  an  open  one.  The 
craving  for  suicide  often  exists  without  the  pluck  to 
carry  the  intention  into  execution,  and  even  among  the 
insane,  many  are  saved  from  suicide  by  the  lack  of 
courage  ;  but,  on  the  other  hand,  in  many  cases  the 
determination  is  so  fixed  and  obstinate  that  the  most 
unlikely  means  are  employed  for  the  purpose,  the 
greatest  ingenuity  and  industry  are  exercised  in  finding 
an  opportunity,  and  nothing  but  unceasing  vigilance 
will  suffice  to  prevent  the  act.  A  fragment  of  cup  or 
tumbler,  of  window-pane  or  chamber-pot,  will  furnish  a 


36  A  TEXT-BOOK  OF  INSANITY 

cutting  instrument  which  will  serve  to  open  a  vein  or  an 
artery.  A  ligature  will  be  found  in  a  garter,  an  apron- 
string,  a  shred  of  clothing  or  sheet,  or  of  unravellings 
twisted  together  to  form  a  string.  A  couple  of  inches 
of  water  in  a  ditch  or  bath  will  suffice  for  drowning ; 
the  back  of  a  chair  or  the  rail  of  a  bedstead  is  high 
enough  for  a  gallows  ;  a  handkerchief  squeezed  into  a 
ball  may  be  stuffed  into  the  throat ;  petroleum,  or 
furniture  polish,  or  anything  that  seems  nasty  and 
unwholesome,  may  be  swallowed  ;  and  thus  the  re- 
sources of  the  would-be  suicide  are  always  at  hand,  and 
the  only  efficient  preventive  is  incessant  and  vigilant 
watchfulness. 

Short  of  suicide,  the  melancholic,  who  is  deeply 
impressed  with  his  own  unworthiness,  will  endeavour 
to  diminish  and  obviate  his  comfort  as  far  as  he  can. 
If  he  will  eat  food  at  all,  it  must  not  be  savoury  or 
daintily  served  ;  his  bed  must  be  hard,  his  clothing 
coarse,  his  occupation  distasteful.  He  insists  upon  a 
morbid  and  unreasoning  asceticism. 

The  third  class  of  activities  of  which  conduct  is 
made  up  comprises  those  which  Spencer  has  termed 
indirectly  self-conservative — those  by  which  the  liveli- 
hood is  earned  and  the  means  are  administered  ;  and 
these  also  are  often  defective  and  sometimes  perverted. 
When  defective,  the  defect,  as  in  the  previous  class, 
may  be  either  original  or  acquired ;  the  activities 
may  never  have  been  attained,  or,  once  attained,  they 
may  be  lost. 

Original  defect  of  the  indirectly  self-conservative 
activities  is  seen  in  two  forms  :  the  first,  in  which  the 
general  level  of  intelligence  is  low,  and  the  defect  is  but 
a  part  and  a  manifestation  of  a  general  defect  implicating 
all  forms  of  conduct ;  the  second,  in  which  the  defect 


ECONOMIC  CONDUCT  37 

is  either  confined  to  this  particular  division  of  conduct 
or  is  in  it  much  more  pronounced  than  in  any  other, 
the  remaining  divisions  being  comparatively  complete, 
and  the  general  level  of  intelligence  up  to  the  normal. 
The  first  of  these  classes  is  constituted  by  the  imbeciles, 
by  those  who  attain  to  the  directly  self-conservative 
activities,  but  fail  to  progress  further  ;  or  who  attain 
to  some  degree  of  conduct  of  this  second  class,  but  who 
can  never  attain  to  the  skill  in  any  occupation  that 
is  necessary  to  give  their  labour  sufficient  market 
value  for  their  support.  They  can  do  simple  work, 
but  they  cannot,  unless  carefully  supervised,  do  even 
the  simplest  work  without  making  such  blunders  as 
deprive  the  work  of  all  value  ;  and  when  the  cost 
of  the  supervision  is  deducted  from  the  value  of  the 
labour,  the  balance  is  too  small  for  them  to  live  on. 
If  they  are  set  to  weed  a  garden,  they  will  pull  up 
weeds  and  valuable  plants  indiscriminately  ;  if  they 
are  set  to  beat  a  carpet,  they  will  vigorously  beat 
it  into  a  hole  at  one  spot  and  leave  the  remainder  un- 
touched ;  tools  they  will  either  break  or  injure  them- 
selves with  ;  letters  they  lose,  or  deliver  to  any  one 
but  the  addressee  ;  and  so  forth. 

Inability  to  earn  a  living  may  be  due  to  a  totally 
different  defect.  To  earn  a  livelihood  requires  moral 
as  well  as  intellectual  qualities.  It  needs  steady  in- 
dustrj^.  It  requires  such  self-control,  such  self-denial, 
such  a  degree  of  self-abnegation,  as  will  allow  of  the 
steady  pursuit  of  an  uninviting  and  perhaps  repellent 
employment,  in  spite  of  the  solicitation  of  others  by 
which  immediate  pleasure  may  be  gained.  It  means, 
in  short,  the  postponement  of  immediate  pleasure  and 
the  suffering  of  immediate  pain,  for  the  sake  of  greater 
pleasure  to  be  enjoyed  in  the  future.    And  this  ability 


38  A  TEXT-BOOK  OF  INSANITY 

of  self-control  differs  very  widely  in  different  people, 
and  is  by  no  means  a  function  of  the  intellectual  ability. 
Either  may  be  highly  developed  while  the  other  remains 
distinctly  below  the  average  ;  and  we  frequently  meet, 
on  the  one  hand,  with  stupid  people  whose  sense  of  duty 
is  highly  developed,  and  in  whom  self-control  increases 
into  self-denial,  and  self-denial  is  pushed  to  asceticism  ; 
while,  on  the  other  hand,  it  is  as  frequent  to  meet 
with  clever  people,  persons  of  nimble  intellect  and 
many  accomplishments,  who  are  so  deficient  in  this 
moral  quality  that  they  are  incapable  of  continuing 
any  mode  of  occupation  after  it  has  ceased  to  be 
pleasant  and  congenial  to  them.  Such  people  are 
deficient  in  the  activities  of  the  class  now  under  con- 
sideration. They  are  incapable  of  earning  their  live- 
lihood, and  incapable  by  reason  of  a  defect,  which 
we  may  term  mental  or  moral  as  we  choose,  but  which 
is  a  defect,  not  in  the  direction  of  idiocy  or  imbecility, 
but  of  a  totally  different  kind. 

The  ability  to  administer  the  means,  when  gained, 
is  of  equal  and  even  of  greater  importance  than  the 
ability  to  earn  a  livelihood  ;  for,  while  the  first  is 
obligatory  upon  every  one,  there  are  many  people  who 
are  relieved  by  the  exertions  of  their  predecessors  from 
all  need  to  earn  their  own  livelihood.  Defect  in  the 
administration  of  the  means  may  take  either  of  the 
forms  exhibited  by  defect  in  the  earning  of  the  liveli- 
hood. It  may  be  due  to  general  defect  of  intelligence, 
so  that  the  subject  of  it  is  imable  to  appreciate  the 
amount  of  his  income,  unable  to  grasp  the  relative 
values  of  different  commodities,  unable  to  appreciate 
the  different  purchasing  power  of  different  sums  of 
money  ;  so  that  he  is  at  the  mercy  of  any  dishonest 
person  who  ohppses  to  ^sk  hm  half  ^  sovereign  for  an 


FACILITY  39 

ounce  of  tobacco  or  a  box  of  matches,  or  to  palm  ofi 
upon  him  a  German  lithograph  as  a  genuine  Raphael, 
a  broken-winded  screw  as  a  certain  winner,  ormolu 
and  glass  as  gold  and  diamonds  ;  so  that  he  expends 
his  income  and  sinks  into  debt  from  sheer  inability 
to  appreciate  the  relation  between  income  and  outgo. 
Few  persons  are  brought  to  ruin  by  this  defect,  how- 
ever, for  it  is  recognised  in  early  life,  and  they  are 
usually  made  wards  of  court  before  they  come  of  age, 
so  that  the  administration  of  their  means  is  never  in 
their  own  control. 

But  the  next  defect  is  a  very  frequent  one,  and 
brings  scores  of  spendthrifts  to  ruin  every  year.  It  is 
the  moral  defect  of  inability  to  postpone  immediate 
pleasure  for  the  sake  of  a  greater  future  benefit.  The 
spendthrift  knows  and  appreciates  the  amount  of  his 
income  ;  knows  that  the  rate  of  his  expenditure  cannot 
be  maintained  without  inroad  upon  his  capital ;  knows 
that  he  is  living  at  a  rate  at  which  his  capital  will  be  ex- 
hausted in  a  few  years  ;  and  yet  the  prospect  of  certain 
ruin  is  insufficient  to  check  his  immediate  indulgence. 

Allied  to  this  defect  is  that  which  is  known  in  Scotch 
law  as  "  facility  "  ;  that  which  is  characterised  by 
an  inability  to  say  "  No  "  ;  and  this  defect  may  be 
original  or  acquired.  Often  it  is  congenital.  There 
are  very  many  persons  of  weak  character  who  are 
unable  to  withstand  solicitation,  who  give  to  every 
beggar  and  lend  to  every  "  sponge  "  money  which  they 
know  they  cannot  well  afford,  from  lack  of  the  moral 
courage,  force  of  character,  or  strength  of  will  to  refuse. 
These  are  the  people  who  are  ruined  by  endorsing 
bills  and  becoming  security  for  their  friends.  Again, 
there  are  people  who,  while  in  the  vigour  of  health, 
are  able  to  repudiate  such  proposals,  but  who  weakly 


40  A  TEXT-BOOK  OF  INSANITY 

accept  tliem  when  enfeebled  by  illness  or  in  the  decay 
of  old  age.  These  are  the  people  whose  wills  are  dis- 
puted upon  the  ground  of  undue  influence,  who  make 
wills  or  deeds  of  gift  in  favour  of  their  nurses  or  land- 
ladies, to  the  exclusion  of  their  own  near  relatives. 

The  administration  of  the  means  may  be  perverted. 
The  instinct  of  accumulation  may  be  present  in  such 
excess  that  expenditure  is  grossly  inadequate.  A  man 
who  is  well  able  to  afford  a  house  and  a  decent  estab- 
lishment will  live  in  a  single  room,  cook  his  own  food, 
go  without  such  decencies  of  life  as  table-linen,  carpets, 
clean  crockery,  or  change  of  clothes,  deny  himself  the 
use  of  artificial  light,  restrict  to  a  dangerous  extent 
his  fire,  live  a  stranger  to  soap,  comb,  blacking,  and 
clothes-brush.  When  economy  is  pushed  to  such  a 
degree  of  miserliness  as  in  the  cases  of  Daniel  Dancer 
and  John  Elwes,  the  perversion  of  conduct  in  itself 
constitutes  insanity. 

The  next  class  of  activities  are  those  by  which  the 
individual  maintains  his  relations  with  the  community 
to  which  he  belongs,  and  these,  like  other  activities, 
are  susceptible  of  defect  and  perversion. 

Communities  exist  by  virtue  of  the  self-restraint  of 
the  component  individuals,  by  which  self-regarding 
activity  is  limited  so  that  the  activities  of  the  other 
members  of  the  community  shall  have  free  play  within 
similar  limits  ;  and  in  order  that  the  community  may 
hold  together  and  continue,  each  individual  must  do 
things  for  the  common  welfare  which,  if  he  lived  in 
solitude,  he  might  without  detriment  leave  undone. 
When  he  lives  in  a  community,  he  must  so  restrain 
and  regulate  his  activity  as  not  to  impair,  nor  even 
to  jeopardise,  the  safety,  the  property,  and  the  self- 
respect  of  his  neighbours ;    and  more  than  this,  he 


SELF-RESTRAINT  41 

must  take  his  share  of  the  common  burdens.  He  must 
contribute  to  its  security  and  defence  both  from  in- 
ternal and  external  dangers  ;  he  must  contribute  to  its 
solidarity  and  cohesion,  not  only  by  abstinence  from 
disintegratory  conduct,  but  by  an  active  execution  of 
such  deeds  as  draw  closer  the  bonds  of  fellowship  and 
knit  more  securely  the  strands  of  society.  He  must 
abstain  from  violence,  dishonesty,  and  slander  ;  and, 
above  and  beyond  this  abstinence,  he  must  exercise 
self-restraint  in  those  hundred  little  ways  by  which  the 
conduct  of  a  person  in  the  presence  of  others  is  shorn 
of  indulgences  which  he  allows  himself  when  alone. 
He  must  pay  taxes,  serve  on  juries,  and  contribute 
by  similar  exercises  to  the  common  welfare  ;  and,  in 
addition  to  this,  he  must  perform  those  acts  of  cere- 
monial and  small  benevolence  which,  under  the  name 
of  politeness  and  courtesy,  diminish  repulsion  and 
increase  cohesion  among  the  units  of  which  the  society 
consists.  Thus  each  form  of  conduct,  whether  in- 
hibitory or  active,  is  divisible  into  a  major  and  a  minor 
section  ;  and  while  the  opportunities  and  occasions  for 
the  exercise  of  the  activities  of  the  major  section  are 
comparatively  infrequent  and  few,  the  opportunities 
and  occasions  for  the  exercise  of  the  minor  activities 
are  frequent  and,  so  long  as  the  individual  is  in  the 
presence  of  his  fellows,  continuous.  Each  major  section 
may  be  dealt  with  separately,  while  the  minor  may  be 
considered  together. 

The  exercise  of  self-restraint,  when  it  is  directed  to 
the  forgoing  of  whatever  advantage  may  be  gained  by 
injuring  others  in  person,  or  property,  or  feeling,  is 
termed  "  morality  "  ;  and  the  doing  of  such  injurious 
acts  is  "  immorality,"  and  may  or  may  not  be  crime, 
according  as  it  is  or  is  not  pimishable  by  law.     Im- 


42  A  TEXT-BOOK  OF  INSANITY 

morality  and  crime,  while  they  are  disorders  of  conduct 
in  the  sense  that  they  are  departures  from  what  the 
universal  consent  of  mankind  admits  that  conduct  ought 
to  be,  are  not  necessarily  disorders  in  the  sense  that  they 
partake  of  the  nature  of  insanity.  They  may  be  sane 
or  insane  according  to  circumstances,  and  the  reader 
who  is  interested  in  the  circumstances  which  dis- 
tinguish the  sane  from  the  insane  variety  of  immorality 
and  crime  should  consult  the  article  on  *'  Vice,  Crime, 
and  Insanity "  in  Clifford  Allbutt's  "  System  of 
Medicine,"  and  the  present  writer's  book  on  *' Criminal 
Kesponsibility." 

The  ability  to  serve  the  community  in  active  ways, 
whether  by  partaking  in  its  defence  against  internal  or 
external  foes,  or  by  undertaking  municipal  or  political 
duties,  is  precisely  the  same  kind  of  ability  as  is  re- 
quired for  the  furtherance  of  the  welfare  of  the  indi- 
vidual himself,  and  the  same  act  which  is  undertaken 
for  the  one  end  often  serves  the  other  ;  so  that  no 
separate  treatment  of  the  defects  and  disorders  of  this 
division  of  conduct  is  needed. 

It  is  in  the  minor  activities  of  social  life,  in  matters 
of  politeness,  of  convention,  of  ceremony,  of  courtesy, 
that  defect  and  disorder  of  conduct  first  exhibit  them- 
selves in  those  cases  in  which  insanity  comes  on  slowly, 
or  in  which  it  does  not  advance  far.  As  these  are  the 
latest  activities  to  be  acquired,  so  they  are  the  earliest 
to  decay  in  those  cases  in  which  an  order  of  decay  can 
be  discerned.  When  the  defect  of  conduct  is  merely 
quantitative — when,  that  is  to  say,  there  is  a  general 
diminution  of  the  amount  of  energy  available  for 
expenditure  in  conduct,  as  in  the  gradual  advance 
of  age — then  defect  is  first  and  most  perceptible  in 
those  forms  of  conduct  that  denxand  for  their  actua- 


GENERAL  FAILURE  OF  CONDUCT        43 

tion  the  largest  amounts  of  energy,  and  activities  are 
abandoned  in  the  order  of  the  vigour  which  they  need 
and  of  the  fatigue  which  they  entail.    Athletic  exercises, 
jumping,  running,  climbing,  rowing,  and  so  forth,  are 
the  first  to  go  ;  and  the  acts  of  politeness  and  courtesy 
which  make  so  small  a  demand  upon  vigour  and  energy 
are  retained  to  the  last.     But  when,  as  in  insanity, 
conduct  suffers   what  may   be   termed   a   qualitative 
defect — when  activities  are  lost  without  respect  to  the 
amount  of  energy  needed  for  their  execution,  but  in  the 
inverse  order  of  their  acquirement — then  these  little 
offices  are  the  first  to  show  defect.     In  a  large  pro- 
portion of  cases  of  insanity  defect  of  these  qualities 
is  unnoticed,  for  the  insanity  comes  on  so  rapidly  that 
the  more  fundamental  and  important  activities  of  self- 
conservation  are  reached  at  the  outset,  or  very  early  in 
the  course  of  the  malady  ;   and  the  disorder  or  defect 
of  these  is  such  an  important  and  such  a  conspicuous 
factor  in  the  case  that  the  loss  of  the  others  passes 
unnoticed.    When  a  house  is  shaken  by  an  earthquake, 
we  are  too  apprehensive  of  the  collapse  of  the  roof  and 
walls  to  notice  the  breakage  of  the  crockery.    Thus  it 
happens  that,  in  a  large  proportion  of  cases  of  insanity, 
defect  and  disorder  of  these  qualities  do  not  need  to 
be  considered.     But  there  is  a  numerous  and  very 
important   class   of   cases — cases   that   are   the   most 
difficult  of  all  to  deal  with  in  practice — in  which  these 
minor  activities  alone  exhibit  disorder,  and  then  it  is 
often  difficult  to  recognise  that  insanity  exists  ;    diffi- 
cult, when  one  has  satisfied  oneself,  to  convey  the  con- 
viction to  others  ;    and  often  impossible  to  establish 
a  sufficient  degree  of  insanity  to  set  the  law  in  motion 
and  sequestrate  the  individual  from  the  management 
ol  himself  and  his  affairs. 


44  A  TEXT-BOOK  OF  INSANITY 

When  the  minor  social  activities  are  disordered, 
then  the  minor  activities  among  the  self-conservative 
and  reproductive  activities  are  usually  disordered  along 
with  them  ;  and  disorder  of  the  whole  group  of  minor 
phases  of  conduct  may  now  be  considered  together. 

The  beginnings  of  insanity,  when  insanity  begins 
slowly,  are  often  very  slight.  The  irritable  man  shows 
such  an  increase  of  irritability  as  makes  his  family 
stare ;  the  talkative  man  monopolises  conversation 
more  completely  than  usual ;  the  uxorious  man  becomes 
even  more  demonstrative ;  the  egotist  brags  more 
audaciously ;  the  querulous  complains  more  bitterly ; 
the  moody  man  has  longer  and  more  frequent  periods 
of  deeper  gloom  ;  any  little  peculiarity  of  conduct 
which  is  native  and  not  assumed  becomes  exaggerated. 
In  this  stage  insanity  is  not  recognised  ;  indeed,  in 
this  stage  insanity  does  not  exist.  It  needs  a  wider 
departure  from  the  normal  to  justify  us  in  diagnosing 
insanity,  but  yet  this  is  the  beginning  of  the  malady  ; 
the  difference  between  this  state  and  recognisable 
certifiable  insanity  is  a  quantitative  difference,  a 
difierence  of  degree  only,  and  a  further  advance  of 
the  malady  is  marked  at  first  by  an  exaggeration  of 
the  same  defects. 

But  if  the  most  conspicuous  features  in  the  man's 
normal  conduct  were  artificial  and  assumed,  if  they 
were  the  expression,  not  of  deeper  and  more  funda- 
mental peculiarities  of  nerve  structure,  but  of  characters 
of  late  acquirement,  and  therefore  of  little  fixity  and 
endurance,  then  the  mark  of  the  onset  of  insanity 
is  a  "  change  in  the  nature  "  of  the  man,  and  the  change 
is  always  in  the  direction  of  degradation.  The  kindly 
and  forbearing  man  becomes  irritable  and  quarrelsome  ; 
the  reticent  man  becomes  expansive,  and  expatiates 


PLAUSIBLE  INSANITY  45 

to  strangers  and  servants  upon  the  misdeeds  of  members 
of  his  family  ;  the  refined  and  gentlemanly  man  con- 
sorts with  artisans  and  labourers,  and  frequents  low 
public-houses  ;  the  man  of  cleanly  life  visits  brothels, 
and  chums  with  loose  women  ;  the  cautious,  prudent 
man  of  business  launches  out  in  wild  speculations  ; 
the  modest,  retiring  man  thrusts  himself  forward  into 
all  kinds  of  society,  writes  long  and  familiar  letters  to 
persons  with  whom  he  has  only  a  bowing  acquaintance, 
asking  favours,  offering  benefits,  and  making  appoint- 
ments ;  the  parsimonious  man  becomes  lavish,  and 
the  generous  man  parsimonious. 

In  this  early  stage  of  the  malady  no  intellectual 
defect  may  be  apparent,  or  if  there  be  any  intellec- 
tual defect,  it  is  displayed  only  in  the  inability  to 
recognise  and  realise  the  impropriety  of  the  conduct. 
If  you  remonstrate  or  reason  with  him,  you  will  be 
astonished  at  the  astuteness  with  which  he  justifies 
and  accounts  for  his  conduct.  You  adduce  instances 
of  his  irritability  and  quarrelsomeness,  and  he  admits 
that  he  lost  his  temper,  but,  then,  consider  the  pro- 
vocation !  and  he  gives  you  an  account  of  the  incident, 
not  wilfully  garbled,  but  highly  coloured,  and  such 
as,  if  you  admit  that  it  appeared  so  to  him,  you  must 
admit  that  his  retaliation  was  not  excessive.  Does 
he  consort  with  labourers  in  low  public-houses  ?  He 
was  unable  to  sleep,  and  at  four  o'clock  on  a  summer 
morning  he  dressed  and  went  abroad.  He  has  always 
been  interested  in  the  lives  of  the  labouring  class,  has 
held  night-schools  for  them,  and  started  slate  clubs, 
and  so  forth.  On  this  morning  he  met  some  of  his 
former  pupils  going  to  their  work,  and  naturally  began 
to  talk  to  them  ;  the  conversation  became  so  interesting 
that  he  accompanied  them  to  the  house  where  they 


46  A  TEXT-BOOK  OF  INSANITY 

took  their  breakfast,  and  then  could  do  no  less  than 
stand  them  beer  all  round.  Tell  him  that  he  is 
squandering  his  means,  and  he  will  almost  convince  you 
in  spite  of  yourself  that  his  expenditure  was  justified ; 
that,  in  the  first  place,  he  could  afford  a  flutter  ;  and, 
in  the  second,  the  chances  of  success  in  his  venture  were 
so  great  as  to  justify  the  speculation. 

Disorder  of  other  divisions  of  conduct  is  scarcely  of 
sufficient  importance  to  need  separate  consideration. 
Defect  of  religious  conduct  is  common  enough  without 
carrying  with  it  any  implication  of  insanity ;  but 
excess  and  disorder  are  occasionally  seen,  and  are 
more  decidedly  abnormal.  When  a  girl  passes  whole 
days  and  nights  upon  her  knees  in  prayer,  and  cannot 
be  prevailed  upon  to  rise,  even  to  eat  and  drink,  or 
to  take  her  fair  share  in  the  duties  of  the  household  ; 
when  a  youth  enters  his  father's  office,  harangues  the 
assembled  customers  upon  their  sins,  prays  aloud  for 
them,  and  finally  dismisses  them  with  his  blessing  ; 
the  morbid  degree  of  the  excess  is  no  longer  in  doubt ; 
but  such  disorder  of  the  religious  portion  of  conduct  is 
rarely  the  most  important,  is  rarely  even  the  most 
conspicuous  disorder.  It  is  not  so  much  the  time 
spent  in  prayer  as  the  neglect  of  all  other  and  more 
urgent  duties  that  is  the  important  disorder  in  the 
first  case  ;  it  is  not  so  much  in  the  second  case  the 
prayer,  as  the  inability  to  appreciate  the  inappropriate- 
ness  of  his  conduct,  that  is  the  important  element  in 
the  conduct  of  the  youth. 

The  whole  subject  of  Conduct  and  its  Disorder  is  dealt 
with  fully  and  elaborately  in  my  book  so  entitled,  which 
is  the  foundation  of  the  study  of  insanity  for  the 
advanced  student. 


CHAPTER   III 


MIND 


Although,  as  lias  been  said,  insanity  is  not  exclusively, 
nor  even  primarily,  disorder  of  mind,  and  although  there 
are  many  disorders  of  mind  that  are  not  insane,  yet 
some  part  of  mind  is  always  disordered  in  insanity,  and 
no  account  of  insanity,  or  of  the  institutes  or  pro- 
legomena of  insanity,  would  be  complete  in  which  the 
constitution  of  mind  and  the  disorders  of  mind  were 
ignored. 

It  is  many  years  since  I  first  urged  that  since  mind  is 
always  disordered  in  insanity,  and  since  the  study  of 
order  and  of  the  normal  should  always  precede  the 
study  of  disorder  and  of  the  abnormal,  therefore  an 
indispensable  preliminary  to  the  study  of  insanity  is  the 
study  of  the  normal  mind,  and  every  alienist  should 
prepare  himself  for  the  study  of  insanity  by  acquiring 
a  competent  knowledge  of  psychology.  This  doctrine 
has  at  length  been  accepted,  and  to  adopt  a  saying  of 
the  late  Sir  Vernon  Harcourt,  we  are  all  psychologists 
now  ;  but  the  result  has  been  not  a  little  disappointing. 
The  study  of  normal  psychology,  as  taught  in  authorita- 
tive text-books,  has  proved  of  very  little  use,  I  may  say 
of  no  use  at  all,  in  assisting  us  to  comprehend  insanity. 
I  can  scarcely  recall  a  single  instance  in  all  the  writings 
of  alienists  of  any  application  to  insanity  of  any  doctrine 
taught  in  any  text-book  of  psychology,  nor  do  I  find  that 

47 


48  A  TEXT-BOOK  OF  INSANITY 

a  knowledge  of  psychology,  as  taught  in  any  book  on 
the  subject,  has  been  of  the  slightest  use  to  myself  or 
to  anyone  else,  either  in  the  investigation  of  any  indi- 
vidual case  of  insanity,  or  in  the  systematic  study  of 
insanity  at  large. 

If  we  compare  this  result  with  the  result  of  the 
corresponding  study  of  the  pathology  of  the  nervous 
system,  we  are  struck  by  the  discrepancy.  Knowledge 
of  the  pathology  of  the  central  nervous  system  has 
proceeded  fari  passu  with  knowledge  of  its  physiology  ; 
and  our  knowledge  of  both  has  advanced  by  leaps  and 
bounds  in  the  last  thirty  years,  while  our  knowledge  of 
the  physiology  and  pathology  of  the  mind  has  been 
almost  stationary.  The  moment  we  inquire  into  the 
reason  of  this  discrepancy  we  are  struck  by  the  fact  that 
our  knowledge  of  the  physiology  of  the  central  nervous 
system  is  derived  very  largely  from  a  study  of  the 
changes  produced  by  disease.  It  was  by  studying  the 
effects  of  disease  on  the  central  nervous  system  that 
Hughlings-Jackson  made  those  discoveries  that  after- 
wards received  experimental  corroboration  from  the 
researches  of  Hitzig  and  Ferrier  ;  and  ever  since  then 
the  study  of  disease  has  gone  hand  in  hand  with  ex- 
perimental research  in  elucidating  the  physiology  of 
the  central  nervous  system.  In  psychology,  the  experi- 
mental method  is  not  open  to  us,  for  the  mind  of  man  is 
so  immeasurably  superior  to  the  minds  of  even  the  most 
intelligent  animals,  that  conclusions  cannot  be  carried 
across  from  the  one  to  the  other  ;  and  moreover,  as  I 
have  so  often  insisted  with  so  little  efiect,  we  cannot 
observe  directly  the  mental  states  and  processes  of 
others.  But  for  the  study  of  mind  we  have  at  our  service 
a  method  that  is  not  available  for  the  study  of  the 
central  nervous  system.    We  have  the  method  of  intro- 


PSYCHIATRIC  PSYCHOLOGY  49 

spection,  by  which  each  one  can  investigate  his  own 
mind,  and  observe  what  passes  therein.  This  method 
takes  the  place,  in  the  study  of  mind,  that  is  taken  by 
experiments  on  animals  in  the  study  of  the  central 
nervous  system  ;  but  whereas  in  the  latter  the  results 
of  experiments  are  perpetually  collated  with  the  results 
of  disease  in  the  human  subject,  in  the  former  the 
results  of  introspection  have  never  been  collated  with 
the  phenomena  of  disease  ;  and  consequently  the  two 
methods  of  research  have  afiorded  no  assistance  to 
each  other,  and  their  results  have  diverged  so  widely 
that,  until  some  effort  is  made  to  collate  them,  they  can 
afford  no  assistance  to  each  other. 

It  is  found  by  the  physician  that  certain  faculties  of 
mind  are  frequently  disordered,  and  the  disorder  of 
them  is  a  prominent  and  important  symptom  in  the 
cases  that  come  before  him ;  but  when  he  turns  to 
psychology  for  a  description  of  these  faculties,  he  finds 
that  they  are  not  mentioned,  and  that  psychologists 
do  not  know  of  their  existence.  For  instance,  Self- 
estimation,  which  undergoes  such  extremely  important 
disorders  in  insanity,  is  not  so  much  as  mentioned  in 
any  book  of  psychology  known  to  me.  Nothing  is 
more  important  to  the  student  of  insanity,  and  to  the 
student  of  sane  disorders  of  mind,  than  the  grading  of 
the  several  mental  faculties  into  their  several  evolution- 
ary levels  or  strata,  without  which  it  is  quite  impossible 
to  understand,  much  less  to  localise,  the  different 
disorders  of  mind,  or  to  distinguish  those  that  are 
compatible  with  sanity  from  those  that  are  insane  ; 
yet  no  attempt  to  distinguish  any  evolutionary  grade 
except  the  lowest  is  made  in  any  book  on  psychology. 
While  these  factors  in  mind  that  are  so  important  to 
the  student  of  the  disordered  mind  are  omitted  from 

E 


50  A  TEXT-BOOK  OF  INSANITY 

every  treatise  on  psychology,  these  treatises  devote  a 
very  large  proportion  of  their  space,  and  assign  a  very 
prominent  position,  to  matters  that  are  to  the  alienist 
utterly  unimportant  and  useless.  The  whole  analysis. of 
Sensations,  in  as  far  as  it  is  of  value  at  all  in  medicine, 
is  relegated  to  the  province  of  the  physiologist  and  the 
general  physician,  and  does  not  concern  the  alienist  as 
such  ;  nor  need  he  ever  consider,  except  as  an  academic 
exercise,  the  association  of  ideas,  the  nature  and  varieties 
of  attention,  the  relation  of  thought  to  language, 
imagination,  conception,  or  a  hundred  other  topics 
which  the  psychologist  treats  at  length.  The  difierences 
between  Analysis  and  Synthesis,  between  Affirmation 
and  Negation,  between  Association  and  Suggestion, 
are  naught  to  the  alienist ;  what  may  be  the  basis  of 
Time  perception,  or  Space  perception,  or  of  apprehension 
of  Form,  is  a  matter  of  utter  indifference  to  him  ;  the 
various  laws  discovered  by  psychologists — the  laws  of 
Eelativity,  of  Suggestion,  of  Association,  Weber's  Law, 
Fechner's  Law — are  not  violated  in  insanity,  or  if  they, 
are,  the  violation  has  no  significance  whatever  for  the 
alienist ;  and  if  he  ever  learns  what  is  meant  by  Apper- 
ception, he  finds,  when  he  enters  the  wards  of  a  lunatic 
asylum,  that  the  sooner  he  forgets  all  about  it  the  better 
he  will  understand  the  disorders  of  mind  from  which 
his  patients  suffer. 

In  order  to  understand  disorders  of  mind,  to  dis- 
tinguish the  disorders  of  mind  that  are  sane  from  those 
that  are  insane,  to  analyse  disorders  of  mind,  and  to 
localise  and  identify  the  faculty  and  grade  of  mind  that 
are  disordered  in  any  particular  case,  it  is  necessary  to 
forget  all  the  teachings  of  psychologists,  and  to  formu- 
late a  scheme  of  mental  faculties  ad  hoc.  I  do  not  say 
that  the  text-books  of  psychology  are  wrong ;  I  only  say, 


MENTAL  FACULTIES  51 

what  every  alienist  will  corroborate,  that  for  the  purpose 
of  the  alienist  they  are  useless.  For  this  purpose  it  is 
necessary  to  make  such  a  division  and  explication  of 
the  various  faculties  of  mind  as  shall  throw  into  pro- 
minence those  that  are  liable  to  be  disordered,  any  others 
not  so  liable,  or  whose  disorder  cannot  be  discovered, 
being  neglected  ;  and  it  is  of  even  greater  importance 
to  grade  these  faculties  into  what  Hughlings-Jackson 
called  "evolutionary  levels,"  that  is  to  say,  into  degrees 
of  elevation  from  the  simple  to  the  complex,  from  the 
crude  to  the  elaborate,  from  the  fundamental  to  the 
accessory,  from  the  primitive  to  the  derivative,  and 
from  that  which  was  earliest  in  origin  to  the  most 
lately  acquired  product  of  evolution.  Dr.  HughHngs- 
Jackson  marked  of!  in  the  nervous  system  three  such 
grades  or  levels,  lowest,  middle,  and  highest,  but  he 
would  have  been  the  first  to  admit  and  declare  that 
such  levels  are  but  arbitrary  divisions  of  a  series  that 
is,  in  fact,  continuous,  just  as  the  horizontal  bars  of  a 
window  divide  the  gradual  tints  of  the  sunset  sky.  In 
such  a  continuous  gradation  it  is  a  matter  of  mere 
convenience  and  of  arbitrary  convention  how  many 
divisions  we  make  and  where  we  place  them,  and 
therefore  I  have  no  hesitation  in  substitutins  for  the 
three  levels  into  which  Hughlings-Jackson  divided  the 
nervous  system,  a  fourfold  division  of  grades  or  levels 
of  mind,  which  enables  us  to  localise  disorders  with 
greater  minuteness  and  accuracy. 

I  first  divide  the  mind  into  certain  primary  faculties, 
each  of  which  is  found  in  experience  to  be  subject  to 
disorder.  These  are  seven  in  number,  and  five  of  them 
are  then  redivided  into  four  evolutionary  grades  or 
levels,  so  that  if  we  range  the  faculties  side  by  side,  and 
regard  the  horizontal  division  into  levels   as  cutting 


52  A  TEXT-BOOK  OF  INSANITY 

across  them,  we  obtain,  as  it  were,  a  series  of  pigeon- 
holes, vertically  four  deep,  and  numbering  horizontally 
as  many  as  the  faculties  that  we  choose  to  constitute. 
Into  one  of  these  pigeon-holes  every  disorder  of  mind 
should  be  placeable.  Perhaps  it  is  as  well  that  I  should 
declare  that  I  do  not  regard  the  mind  as  composed  of 
pigeon-holes,  nor  do  I  suppose  that  it  is  actually  con- 
stituted on  any  such  plan,  any  more  than  I  suppose 
that  the  surface  of  the  earth  is  truly  represented  by  a 
map  on  Mercator's  projection.  Nevertheless,  maps  are 
useful  helps  to  finding  our  way  about  the  country,  and 
estimating  the  relative  positions  of  places  on  the  surface 
of  the  earth  ;  and  such  a  Mercator's  projection  of  the 
topography  of  the  mind  as  I  propose  will  be  found 
useful  in  understanding  the  intricacies  of  the  mind, 
and  in  estimating  the  relations  of  the  several  parts  that 
participate  or  do  not  participate  in  any  disorder. 

The  plan  by  which  I  represent  the  constitution  of 
mind  is  a  complicated  one,  but  then  the  mind  of  man 
is  extremely  complex,  and  any  simpler  plan  would  not 
represent  that  constitution  with  any  approach  to 
correctness.  I  do  not  say  that  the  plan  that  I  propose 
represents  the  true  relations  of  the  several  faculties 
of  mind,  for  it  is  obvious  that  that  which  is  not  in 
space  can  scarcely  be  accurately  represented  by  spacial 
relations.  My  scheme  does,  however,  provide  a 
systematic  plan  of  a  large  area  of  mind,  a  plan  such 
as  has  not  hitherto  been  in  existence ;  and  although 
some  departments  of  mind  will  not  go  very  comfort- 
ably into  my  pigeon-holes,  and  others  are  advisedly 
omitted  altogether,  and  although  the  scheme  is  ad- 
mittedly crude  and  imperfect,  and  will  no  doubt  be 
found  susceptible  of  improvement  in  the  future,  yet  I 
submit  that  even  a  crude  and  imperfect  plan  is  better 


MENTAL  FACULTIES  53 

than  no  plan  at  all ;  and  I  have  myself  found  it  of  such 
great  assistance  in  investigating  and  classifying  mental 
disorders  that  I  camiot  think  it  will  be  useless  to  others 
who  are  engaged  in  the  same  pursuit. 

The  primary  faculties  into  which  I  divide  the  mind  for 
the  purpose  of  studying  and  locaHsing  mental  disorders 
are  five  : — Desire,  Will,  Feeling,  Thought,  and  Memory, 
or,  since  I  divide  each  into  grades  or  levels,  they  may 
be  termed,  Desires,  Volitions,  Feelings,  Thoughts,  of 
which  the  most  important  are  Beliefs,  and  Memories. 
Two  of  these,  Feelings  and  Thoughts,  are  split  down 
vertically  into  an  objective  and  a  subjective  side,  so 
that  in  all  there  are  seven  primitive  faculties  of  mind. 
All  these,  with  the  exception  of  Memory,  are  again  divided 
horizontally  into  grades  or  evolutionary  levels,  of  which 
I  make  four,  so  that  altogether  there  are  twenty-five 
pigeon-holes  or  compartm^ents,  in  one  or  more  of  which 
every  disorder  of  mind  can  be  placed. 

Let  me  again  declare,  though  no  doubt  I  shall  be 
taken  to  task  just  as  if  the  declaration  had  never  been 
made,  that  although  the  mind  is  rightly  and  naturally 
divisible  on  this  scheme,  yet  the  distinctions  and  divisions 
are  arbitrary,  conventional,  and  made  more  for  the 
purpose  of  practical  convenience  than  of  scientific 
accuracy.  Emotion,  for  instance,  is  classed  among  the 
objective  feelings,  though  it  contains  large  ingredients 
not  only  of  subjective  feeling,  but  of  thought  also. 
Ingenuity  is  classed  on  the  objective  side  of  thought, 
though  it  contains  a  large  subjective  element. 

The  second  principle  of  division,  into  evolutionary 
grades  or  levels,  should  be  familiar  to  every  student  of 
neurology,  and  should  need  little  explanation.  I  take 
it  that  there  is  a  continuous  series  of  desires,  from  the 
crude  desire  for  food  to  the  refined  desire  for  justice ; 


54  A  TEXT-BOOK  OF  INSANITY 

that  there  is  a  continuous  series  of  volitions,  from  the 
elementary  choice  of  this  potato  out  of  the  dish,  or  this 
cigar  out  of  the  box,  to  this  rather  than  that  career  in 
life  ;  of  thoughts,  from  the  simple  perception  of  an 
object  to  the  highest  flights  of  speculative  genius  ;  of 
feelings,  from  the  crude  pleasure  of  eating  and  the 
crude  pain  of  bodily  injury  to  the  refined  pleasures  of 
benevolence  and  sympathy  and  the  refined  pain  of 
bereavement  and  indignation.  In  each  of  these  con- 
tinuous series  I  draw,  at  arbitrary  distances,  three 
transverse  lines,  dividing  them  into  four  levels  or 
strata  ;  and  thus  the  skeleton  outline  of  my  plan  is 
complete.    It  now  remains  to  fill  it  in. 

Before  doing  so,  however,  it  will  be  well  to  state 
generally,  what  will  be  abundantly  illustrated  in  par- 
ticular cases,  that  in  practice  we  find  that  any  one  of 
these  faculties  may  alone  be  subject  to  disorder,  the 
others  remaining  normal,  or  with  only  such  errors  in 
action  as  are  strictly  consequential  to  the  disorder  of 
their  erring  colleague  ;  and  not  only  this,  but  any  level 
of  any  faculty  may  suffer  disorder  without  implicating 
the  level  of  that  same  faculty  above  or  below  the  level 
that  is  disordered.  It  is  this  possibility  and  this  occur- 
rence of  limited  disorder  that  gives  to  the  plan  of  mind 
here  elaborated  most  of  its  validity  and  usefulness.  It 
is  quite  true  that  several  faculties  may  be  simultaneously 
disordered  on  the  same  or  on  difierent  levels,  and  it  is 
true  also  that  any  one  faculty  may  be  disordered  on 
more  than  one  level ;  and  it  is  the  occurrence  of  these 
single  or  multiple  disorders  that  constitute  the  various 
types  and  kinds  of  disorder  of  mind  and  the  various 
forms  of  insanity  ;  but  the  important  thing  is  that 
when  we  have  a  plan  of  this  kind  before  us,  it  constitutes 
a  system  on  which  the  mind  may  be  investigated  ;  and 


DESIRE  55 

it  constitutes  also  a  plan  upon  which  the  disorders  can 
be  mapped  out,  so  that  we  can  see  at  a  glance  in  any 
case  what  faculties  are  disordered,  upon  what  levels, 
and  how  far  the  disorder  extends  in  this  direction  or  in 
that. 

DESIRE 

Insanity  is  disorder  of  conduct,  and  conduct  is 
prompted  and  actuated  by  desire.  Without  desire  to 
achieve  ends,  without  aversion  to.  certain  experiences, 
there  would  be  no  motive  to  conduct,  and  therefore 
no  conduct.  All  conduct  is  undertaken  for  the  satis- 
faction of  some  desire  or  the  avoidance  of  some  aversion, 
which  is  the  complementary  antithesis  to  desire,  and 
the  first  department  or  faculty  of  mind,  the  faculty 
that  lies  at  the  base  of  mind  and  constitutes  its  founda- 
tion, the  faculty  to  which  all  conduct  is  due,  is  Desire. 

The  several  grades  of  desire  correspond  with  the 
several  departments  of  conduct  that  have  been  already 
enumerated  and  examined.  It  has  been  pointed  out 
in  a  previous  chapter  that  all  Hfe  is  teleological — is 
inspired  by  a  purpose — and  that  the  prime  purpose 
of  every  living  thing  is  to  continue  the  stirp  to  which  it 
belongs.  In  the  human  being  this  primary  purpose  is 
so  overlaid  and  obscured  by  a  multitude  of  secondary 
and  subsidiary  purposes,  many  of  which  have  become, 
by  a  process  explained  in  my  book  on  Conduct,  ultimate 
purposes  pursued  for  themselves  alone,  that  the  primary 
end  of  the  life  of  man  is  apt  to  be  forgotten  or  to  remain 
unrecognised,  but  in  him  it  is  the  same  as  in  all  living 
beings  ;  and  since  animate  beings  do  not  strive  to  efiect 
a  purpose  unless  they  are  prompted  and  urged  to  do 
so  by  desire,  the  central  fact  in  mind  is  the  existence 
of  the  desires  of  reproduction  and  of  maternity.    These 


56  A  TEXT-BOOK  OF  INSANITY 

desires,  therefore,  form  the  lowest  stratum  or  level  of 
the  series  or  stack  of  Desires.  Reproduction  cannot 
be  effected  unless  life  is  preserved  to  the  reproductive 
age,  nor  can  the  offspring  be  reared,  nor  reproduction 
be  repeated,  unless  life  is  preserved  after  reproduction 
is  effected  ;  and  hence  self-preservation  is  a  necessary 
preliminary  and  accompaniment  of  reproduction,  and 
the  corresponding  desire  for  self-preservation,  the  dread 
of  death,  of  bodily  injury,  and  of  illness,  are  immediately 
necessary  and  subservient  to  the  racial  desires.  The 
desire  of  self-preservation  from  injury  and  death  forms, 
therefore,  the  second  level  or  stratum  in  the  stack  of 
desires.  But  immunity  from  bodily  injury  is  not  the 
only  condition  necessary  for  the  survival  of  the  indi- 
vidual. If  he  is  to  survive  and  to  reproduce  his  kind, 
it  is  necessary,  as  human  life  is  now  carried  on,  that  he 
should  be  fed,  clothed,  housed,  and  employed  to 
advantage  ;  and  in  order  that  he  may  do  the  things 
necessary  to  secure  these  requisites,  he  must  have  a 
further  set  of  desires — for  occupation,  of  accumulation, 
and  so  forth,  and  these  form  the  third  stratum  in  the 
stack  of  desires.  Lastly,  struggle  for  life  with  cir- 
cumstances, inorganic,  organic,  and  super-organic,  has 
led  to  the  desire,  so  powerfully  effectual  in  securing 
survival,  of  living  together  in  communities  ;  and  the 
exigencies  of  social  life  have  given  rise  to  another 
large  and  important  group  of  desires,  which  prompt 
and  urge  to  conduct  tending  to  preserve  and  consolidate 
and  advance  the  community  to  which  the  acting  indi- 
vidual belongs.  These  form  the  topmost  level  of 
desires,  and  complete  the  four  grades  into  which  this, 
in  common  with  the  other  compartments  of  mind,  is 
divided. 
The  disorders  of  desires  are  for  the  most  part  ex- 


OBSESSION  57 

pressed  in  corresponding  disorders  of  conduct,  and 
what  has  been  said  in  a  previous  chapter  of  disorders  of 
conduct  need  not  be  repeated  here  ;  but  there  is  one 
disorder  of  desire  that  often  struggles  to  express  itself 
in  conduct,  but  that  is  usually  overborne  by  will,  and 
prevented  from  finding  expression.  This  disorder  is 
Obsession,  a  term  that  like  other  terms  in  psychology 
is  constantly  misused.  It  is  employed  to  mean  delusion, 
imperative  idea,  prejudice,  and  other  mental  states. 
The  true  meaning  of  obsession  is .  a  morbid  desire  to 
do  some  act  which  the  would-be  actor  discountenances, 
struggles  not  to  do,  and  can  usually,  probably  always, 
succeed  in  refusing  to  do.  Most  of  us  have  experienced 
at  one  time  or  another  a  minor  and  trivial  form  of 
obsession.  We  find  some  familiar  form  of  words — a 
proverb,  a  line  of  verse,  a  text  from  Scripture,  or  what 
not — "  running  in  the  head."  We  say  it  over  and  over 
again  silently  to  ourselves,  and  as  we  do  so  we  ex- 
perience a  more  or  less  urgent  desire  to  say  it  aloud. 
This  desire  can  be  resisted.  Very  often  it  is  not  re- 
sisted, for  the  whole  afiair  is  so  trivial  that  it  is  not 
worth  while  to  summon  up  the  will  to  overpower  the 
desire ;  so  at  length  the  words  get  themselves  uttered 
aloud.  Or  it  may  be  that  in  walking  along  the  street, 
we  have  the  absurd  and  irrational  desire  to  step  upon 
the  divisions  between  the  flagstones,  or  to  avoid  step- 
ping upon  them,  as  the  case  may  be,  and  here  again, 
the  desire  is  often  not  resisted  because  it  is  not  worth 
while  to  resist  it.  It  is  allowed  to  have  its  way,  and  we 
regulate  our  footsteps  accordingly.  But  we  feel  all  the 
while  that  we  could  resist  if  we  pleased,  and  could  if 
we  chose  disregard  the  desire,  and  pursue  our  walk 
without  reference  to  it.  Sometimes,  however,  the 
obsession  is  not  of  this  innocent  nature.     The  words 


58  A  TEXT-BOOK  OF  INSANITY 

that  arise  in  the  mind  and  clamour  for  utterance  may 
not  be  mere  innocent  proverbs  or  texts  ;  they  may  be 
objurgatory,  or  obscene,  or  blasphemous.  The  act  that 
suggests  itself  and  demands  execution  may  be  not  the 
innocent  act  of  stepping  on  or  avoiding  the  divisions 
between  the  flagstones  :  it  may  be  the  act  of  cutting 
a  throat  or  throwing  a  child  out  of  window.  In  such 
cases  it  is  urgently  necessary  to  summon  up  the  will  to 
inhibit  and  prevent  the  execution  of  the  act ;  and  in 
experience  it  is  found  that  the  will  has  almost  always 
sufficient  power  and  authority  to  keep  order  in  the 
mental  household  and  prevent  the  perpetration  of  the 
act.  There  are,  indeed,  a  few  cases  on  record  in  which 
the  will  has  been  felt  incapable  of  resisting,  and  external 
aid  has  been  sought.  The  unfortunate  sufferer  has  given 
himself  up  to  the  police,  or  sought  the  shelter  of  an 
asylum,  andbegged  to  be  physically  restrained  from  carry- 
ing out  a  purpose  that  he  felt  was  not  his  purpose  ;  and 
now  and  then  a  case  has  occurred  in  which  some  minor 
obsession,  such  as  that  to  steal  objects  of  a  certain  class, 
has  been  yielded  to.  But  it  is  still  doubtful  whether  the 
will  would  have  been  ineffectual  to  restrain  these  acts 
if  it  had  been  sufficiently  appealed  to.  No  doubt,  when 
the  obsession  is  unusually  intense  and  persistent,  such 
sufferers  do  become  after  a  time  weary  of  the  struggle, 
but  in  the  cases  in  which  they  place  themselves  under 
restraint,  it  is  clear  that  their  wills  are  competent  to 
overcome  the  morbid  desire  up  to  the  time  of  so  placing 
themselves,  and  my  own  opinion  is  that  such  persons 
place  themselves  under  restraint,  not  so  much  because 
they  feel  their  wills  giving  way,  but  in  order  to  obtain 
relief  from  the  fatigue  of  the  conflicts  between  will  and 
desire.  In  the  rare  cases  of  stealing  under  obsession,  I 
believe  that  the  appeal  to  will  was  ineffectual  because 


VOLITION  59 

it  was  half-hearted — in  other  words,  that  the  thief 
could  have  resisted,  but  did  not. 

In  all  cases  of  obsession,  what  happens  is  a  conflict 
between  a  lower  desire  and  one  that  is  more  elevated, 
an  occurrence  that  is  frequent  enough  in  the  experience 
of  us  all.  WTiat  stamps  the  obsessive  desire  as  morbid, 
and  removes  the  conflict  from  the  class  that  is  so 
frequent  with  us  all,  is  its  unprofitable  character.  The 
desire,  if  carried  out  into  action,  would  do  the  actor 
no  good.  He  would  not  benefit,  nor  would  anyone  else 
benefit  by  the  accomplishment  of  the  purpose  represented 
by  the  desire.  This  is  true  even  of  obsessions  to  steal, 
for  the  objects  on  which  the  obsession  fixes  are  not 
usually  objects  whose  possession  would  materially 
benefit  the  obsessed. 

In  obsession,  then,  we  witness  a  disorder  of  desire, 
whose  nature  is  a  rebellion  of  a  lower  desire,  a  desire 
whose  purpose  is  always  useless,  and  is  sometimes 
highly  pernicious  to  the  person  by  whom  it  is  felt, 
against  the  higher  desires  for  his  own  welfare  and  that 
of  those  who  are  near  and  dear  to  him.  It  is  the  rebellion 
of  a  lower  level  against  a  higher  level,  the  like  of  which 
we  shall  witness  again  and  again  in  the  other  faculties, 
and  thus,  although  it  is  always  regarded  as  a  unique, 
a  bizarre,  and  an  unaccountable  disorder,  we  find  that 
it  ranges  itself  along  with  others,  and  belongs  to  a  class 
of  mental  disorders  that  is  by  no  means  uncommon. 


WILL 

As  has  been  said,  Desire  is  the  motive  of  all  conduct, 
and  without  the  prompting  and  urging  of  desire,  animate 
beings  would  undertake  no  action,  and  display  no 
conduct ;   but  between  desire  and  action  there  inter- 


60  A  TEXT-BOOK  OF  INSANITY 

venes  a  second  mental  factor,  without  which  desire, 
however  urgent  and  overwhelming,  would  never  find 
expression  in  action.  This  factor  is  Will,  or  Volition, 
the  immediate  antecedent,  and  as  far  as  we  know,  the 
immediate  cause,  of  action.  In  the  experience  of  us 
all,  desires  often  conflict.  One  desire  pulls  this  way, 
another  pulls  that :  one  desire  prompts  to  a  certain 
course  of  action,  another  to  the  opposite.  It  seems 
that  in  such  a  case  the  stronger  desire  will  and  must 
prevail,  but  examination  of  our  own  consciousness  does 
not  support  this  view.  It  seems,  if  we  watch  the 
turmoil  in  our  own  minds,  that  on  some  occasions  will 
intervenes,  and  gives  the  weaker  desire  dominance  over 
the  stronger.  However  that  may  be,  it  is  as  certain 
as  universal  experience  can  make  it  that  whatever  the 
urgency  of  a  desire  may  be,  it  can  to  some  extent  be 
checked  and  controlled  by  the  will,  and  in  no  case  does 
it  find  expression  in  conduct  until  will  gives  its  sanction 
and  exerts  itself  to  produce  the  outward  act.  Volitions, 
then,  constitute  the  second  of  the  great  faculties  of 
mind,  the  second  nest  of  pigeon-holes  into  which  mind 
is  for  convenience  divided;  and  volitions,  like  other 
mental  processes,  may  be  graded  into  levels. 

On  the  highest  level  are  those  volitions  which  deter- 
mine our  conduct  in  the  gravest  and  most  important 
affairs  of  life — ^in  those  matters  which  determine  our 
general  success  or  failure — affairs  whose  success  gives 
rise  to  exultation,  and  whose  failure  causes  despondency. 
On  the  upper  middle  level  are  those  volitions  by  which 
choice  is  made  and  action  determined  of  the  means 
that  should  be  employed  to  attain  the  important 
results  determined  on  by  the  highest  class  of  volitions. 
The  lower  middle  level  is  constituted  of  volitions  on 
matters  less  important  and  subsidiary  to  the  last,  the 


DISORDERS  OF  VOLITION  61 

daily  decisions  about  daily  affairs  ;  and  the  lowest  level 
by  choice  on  trivial  matters  of  momentary  import, 
such  as  which  shoe  or  stocking  to  put  on  first,  which 
book  to  amuse  an  idle  hour  with,  which  peach  or  which 
potato  to  select  out  of  the  dish,  and  so  forth. 

Vohtion  is  subject  to  several  disorders,  which  fall 
naturally  into  two  kinds,  the  spontaneous  and  the 
reflective.  By  a  spontaneous  disorder  of  will,  I  mean 
a  disorder  of  will  which  is  manifested  spontaneously 
by  the  person  affected,  and  does  not  need  the  incidence 
of  circumstances  to  call  it  out.  By  a  reflective  or  elicited 
disorder  of  will,  I  mean  one  which  is  not  manifested 
except  under  the  influence  of  the  wills  of  other  persons. 

The  spontaneous  disorders  of  will  are  three — ^Delay, 
Vacillation,  and  Precipitation.  Whenever  the  will  is 
exerted,  whenever  a  volition  is  effected,  the  mental 
operation  is  preceded  by  an  interval,  which  may  be 
prolonged,  or  may  be  so  brief  as  to  be  inappreciable, 
and  which  is  called  hesitation.  The  duration  of  this 
preliminary  interval  varies  with  the  level  of  the  volition 
that  is  being  exercised.  Volitions  of  the  uppermost 
level  may  normally  be  preceded  by  a  prolonged  period  of 
hesitation.  When  the  choice  to  be  made  is  on  a  m^atter 
that  will  influence  the  whole  of  the  subsequent  life, 
when,  for  instance,  it  is  the  choice  of  a  calling,  or  of 
adhering  to  or  abandoning  a  calling,  or  when  it  is 
whether  the  calling  should  be  followed  at  home  or  abroad, 
whether  an  appointment  of  less  but  certain  advantage 
shall  be  sought  rather  than  one  of  greater  but  less 
certain  advantage,  when  it  is  whether  some  important 
offer  shall  be  accepted,  or  some  important  step  shall 
be  taken,  it  is  legitimate,  normal,  and  desirable  to 
hesitate  long,  and  to  ponder  deliberately,  it  may  be 
for  weeks  or  months,  before  the  volition  is  exercised 


62  A  TEXT-BOOK  OF  INSANITY 

and  the  final  decision  taken ;  but  when  the  matter  in 
question  is  of  the  means  to  carry  out  an  end  already 
determined  upon,  when  it  is  not  whether  we  shall  spend 
the  greater  part  of  our  life  in  India  or  South  Africa  or  at 
home,  or  whether  we  shall  leave  the  Church  of  our 
fathers  and  our  upbringing  and  join  another,  or  enter 
into  partnership  with  Jones  or  not,  or  some  such  mo- 
mentous decision,  but  is  whether  we  shall  take  a  house 
in  this  suburb  or  that,  or  an  office  in  this  street  or  that, 
or  invest  a  spare  thousand  in  this  security  or  that,  a 
hesitation  of  weeks  or  months  would  be  manifestly 
inappropriate  and  excessive.  Hours  or  days  would  be 
long  enough  to  hesitate  over  such  matters  as  this. 
Decisions  on  the  lower  middle  level  may  properly  be 
still  more  brief.  Minutes  would  be  enough  time  to 
consume  in  hesitating  whether  to  send  for  Dr.  Smith 
or  Dr.  Brown  for  the  baby's  illness,  whether  it  is 
necessary  to  go  in  person  from  London  to  Birmingham 
to  transact  the  business,  or  whether  a  letter  will  not 
suffice  ;  whether  to  buy  this  picture  or  that  bracelet 
would  or  would  not  be  unjustifiable  extravagance. 
Finally,  volitions  on  the  lowest  level  are  normally  made 
without  appreciable  hesitation.  In  novels,  it  is  true, 
the  characters  always  "  carefully  select "  a  cigar  out  of 
the  box,  but  anyone  who  did  so  in  real  life  would  be 
stared  at.  A  choice  of  this  kind  is  made  instantaneously, 
and  even  in  buying  a  pipe  or  a  walking-stick,  no  normal 
person  would  hesitate  more  than  momentarily  ;  and  so 
with  the  decision  whether  to  walk  or  take  a  cab  ;  whether 
to  go  to  church  or  stay  at  home,  whether  to  play  billiards 
or  cards,  whether  take  the  short  and  muddy  path  across 
the  fields  or  the  longer  and  cleaner  way  by  the  road, 
may  admit  of  momentary  hesitation,  but  not  of  a  hesita- 
tion that  is  more  than  momentary. 


EXCESSIVE  HESITATION  63 

No  doubt  other  considerations  than  the  importance 
of  the  decision  do  enter  into  the  determination  of  the 
length  of  hesitation,  and  such  determinants  as  the 
number  of  the  alternatives  among  which  the  choice  is 
to  be  made,  and  the  equality  in  advantage  of  the 
difierent  alternatives,  have  an  important  efiect ;  but 
for  the  present  purpose  all  that  we  need  take  into 
account  is  the  importance  of  the  decision,  or  the  evolu- 
tionary level  of  the  volition  concerned. 

The  first  of  the  spontaneous  disorders  of  voHtion  is 
the  undue  prolongation  of  the  period  of  hesitation.  In 
this  disorder  there  is  abnormal  delay  in  "making  up 
the  mind,"  and  it  seems  that  even  when  the  mind  is 
made  up,  and  the  course  of  conduct  decided  upon,  there 
is  some  obstruction  to  the  exercise  of  the  will,  so  that 
the  action  is  delayed.  In  such  cases  not  only  is  some 
choice  of  the  lowest  level,  such  as  which  shoe  or  which 
stocking  is  to  be  put  on  first,  preceded  by  a  period  of 
hesitation  that  may  run  on  for  ten  or  fifteen  minutes, 
but  when  some  simple  act,  such  as  pouring  out  the 
tea,  is  decided  upon,  an  unaccountable  delay  occurs 
before  the  hand  can  be  stretched  out  and  the  teapot 
grasped  and  lifted.  In  the  latter  case  the  interval  is 
usually  occupied  in  giving  way  to  the  obsession  of 
counting.  Before  every  action  of  the  most  trivial 
kind  the  patient  is  obsessed,  and  yields  to  the  obsession 
of  counting,  usually  up  to  ten,  or  some  multiple  of  ten. 
Before  the  teapot  can  be  grasped,  ten  must  be  counted  ; 
before  the  tea  can  be  poured  into  the  cup,  ten  more 
must  be  counted  ;  before  the  milk  can  be  added,  ten 
must  be  counted  again  ;  and  yet  again  before  the 
sugar  is  dropped  in.  In  other  cases  there  is  merely 
excessive  hesitation  without  obsession. 

Closely  allied  to  excessive  hesitation  is  Vacillation, 


64  A  TEXT-BOOK  OF  INSANITY 

a  disorder  which  occurs  at  a  slightly  later  stage,  after 
the  action  is  begun,  and  consists  in  repeated  interruption 
and  renewal  of  an  act.  In  this  disorder  the  patient  will 
not,  as  in  hesitation,  sit  contemplating  his  shoes, 
unable  to  make  up  his  mind  which  to  put  on  first,  but 
will  seize  first  one,  with  the  intention  of  putting  it  on, 
and  will  instantly  abandon  it  and  take  up  the  other. 
He  will  get  the  right  shoe  half  on  and  kick  it  ofi  again 
in  favour  of  the  left,  and  so  he  will  go  on  with  other  acts 
throughout  the  day.  He  decides  to  go  and  buy  some- 
thing— starts  and  comes  back  half  a  dozen  times.  He 
gets  to  the  shop  at  last,  enters  it — and  comes  out  again 
without  making  his  purchase.  He  goes  back  and  selects 
the  pair  of  gloves  he  wants — ^rejects  them  in  favour  of 
another  pair — ^rejects  these  and  takes  the  first  pair — 
rejects  these  again  for  the  second,  and  so  on ;  and  so 
throughout  the  day.  Undue  hesitation  often  exists 
alone,  without  a  trace  of  vacillation,  but  vacillation, 
which  seems  to  be  a  more  advanced  stage  of  hesitation, 
rarely  exists  without  hesitation. 

The  third  variety  of  the  spontaneous  disorder  of 
volition  is  the  reverse  of  undue  hesitation.  It  is 
precipitation  in  volition.  It  is  the  sudden  and  precipi- 
tate willing  of  an  act  whose  advantage  and  disadvantage 
have  received  no  adequate  consideration,  or  have  not 
been  considered  at  all.  Some  degree  of  precipitation 
is  common  enough,  and  does  not  transcend  the  limits 
of  the  normal.  There  are  plenty  of  people  who  act 
impulsively  upon  occasion,  and  who  suffer  the  conse- 
quences of  doing  so,  without  the  impulsiveness  reaching 
the  degree  of  actual  disorder  of  mind.  The  impulsive- 
ness that  constitutes  disorder  is  very  rarely  precipitation 
pure  and  simple ;  that  is  to  say,  it  rarely  or  never 
consists  in  the  precipitate  choice  of  one  out  of  several 


IMPULSIVENESS  65 

sane  and  reasonable  alternatives.  Such  impulsiveness 
is  frequent  enough,  and  may  be  supremely  sane,  for 
there  are  a  few  rare  spirits,  of  whom  Napoleon  Bona- 
parte is  the  most  conspicuous,  who  appear  to  seize 
instantly  and  intuitively,  even  in  the  most  important 
and  most  complicated  afiairs,  upon  the  course  of  conduct 
that  proves  in  those  circumstances  the  most  advan- 
tageous. The  impulsiveness  that  marks  disorder  of 
mind  is  the  precipitate  willing  of  some  act  that  is  itself 
on  the  face  of  it  unreasonable  and  disadvantageous,  and 
that  it  is  dijB&cult  to  believe  that  even  the  disordered 
intellect  would  have  sufiered  the  person  to  choose  if 
time  had  been  allowed  for  a  deliberate  choice  to  be 
made.  Precipitate  volitions  that  are  morbid  are  morbid 
not  only  in  their  precipitation  :  they  are  morbid  also 
in  the  character  of  the  act  that  is  done,  but  still,  the 
impulsiveness  of  the  act  is  its  leading  and  most  dis- 
tinctive quality.  Morbid  impulsiveness  may  show 
itself  in  a  sudden  leap  from  a  window,  and  then  the 
impulsiveness  may  be  so  extreme  that  no  time  is  taken 
even  to  open  the  window  ;  or  it  may  show  itself  by  a 
sudden  tearing  of  the  cloth  ofi  the  table  with  all  the 
covers  and  viands  upon  it ;  or  it  may  show  itself  in  any 
other  sudden  act,  which  may  be  self-destructive,  or 
destructive  of  others,  or  destructive  of  things  merely ; 
but  which  is  usually  destructive  of  something. 

The  reflective  or  elicited  disorders  of  will  are,  as  the 
title  implies,  not  exhibited  except  in  circumstances  that 
call  them  forth  ;  and  these  circumstances  are  the  ex- 
pression of  the  will  of  others.  It  is  a  common  observa- 
tion that  different  persons  differ  normally  both  in  the 
power  of  impressing  their  wills  on  others,  and  in  the 
power  of  resisting  the  will  which  others  seek  to  impress 
on  them,  or  do  impress  on  them  without  seeking  to  do 


66  A  TEXT-BOOK  OF  INSANITY 

so.  Here  we  do  not  consider  the  power  of  impressing 
the  will  on  others,  but  solely  the  power,  and  aptitude, 
and  practice  of  resisting  the  will  or  the  suggestion  of 
other  people.  This  power,  normally  variable,  attains 
in  disease  to  extremes  that  are  in  themselves  mani- 
festly morbid.  There  are  persons  in  whom  it  is  so 
deficient  that  they  are  at  the  mercy  of  those  around  them, 
or  more  usually  of  one  person  of  their  acquaintance, 
and  fall  in,  with  canine  obedience,  with  every  suggestion 
that  these  others  or  this  other  may  make  to  them.  Such 
suggestibility  is  recognised  by  Scotch  law  as  an  occa- 
sional feature  in  human  nature,  and  certain  provisions 
of  that  law  are  specially  designed  to  protect  the  Facile 
person  from  plunderers  who  would  take  advantage  of 
his  facility. 

The  opposite  attitude  of  Stubbornness  or  Kesistive- 
ness,  though  not  very  frequent,  is  sufficiently  frequent 
in  insanity  to  render  it  remarkable  that  it  was  never 
described  until  the  description  appeared  in  the  first 
edition  of  this  text-book.  That  description  may  be 
repeated  here  : — Patients  of  this  type  do  not  speak. 
They  make  for  the  door,  the  window,  or  the  fire,  and 
when  restrained  will  continue  for  hours  the  same  silent, 
dogged,  determined  effort  to  reach  the  desired  destina- 
tion. They,  too,  undress  themselves,  but  they  do  so, 
not,  as  the  acute  maniac  does,  from  the  mere  exuberance 
of  their  activity,  which  must  find  some  vent,  it  matters 
not  what,  and  which,  when  restrained  from  taking  oJS 
the  coat,  begins  to  unbutton  the  waistcoat  or  trousers. 
A  patient  of  the  resistive  type  undresses  himself  with 
the  same  blind  dogged  obstinacy  that  he  does  every- 
thing else.  He  persistently,  again  and  again  for  hours 
together,  attacks  the  same  button,  or  tries  to  remove  the 
same  garment  in  the  same  way.    He,  too,  refuses  food, 


SUBJECTIVE  FEELING  67 

but  he  refuses  it  not,  as  far  as  can  be  judged,  with 
suicidal  intent,  but  with  the  same  resistiveness  with 
which  he  stubbornly  opposes  everything  that  is  done 
for  him,  and  everything  that  is  suggested  to  him  to  do 
— refuses  to  be  dressed  and  to  be  undressed,  to  sit  down 
or  stand  up,  to  go  to  the  closet  or  come  away  from  it, 
to  walk  about  or  to  stand  still.  Stubbornness  seems 
to  rest,  in  the  last  resort,  upon  excessive  suspicion,  and 
it  is  probably  on  account  of  the  suspicion,  or  more,  the 
conviction,  that  everyone  is  antagonistic  towards  him, 
that  the  stubborn  person  adopts  his  attitude  of 
stubbornness.  At  present,  however,  we  are  not  con- 
cerned with  the  combinations  of  disorders,  but  solely 
with  single  disorders  of  single  faculties,  and  of  these 
Stubbornness  is  one  of  the  most  pronounced  and 
remarkable. 


FEELING    I.      SUBJECTIVE 

Under  this  heading  I  include  two  difierent  groups  of 
mental  states,  each  of  which  is  susceptible  of  division 
into  the  four  evolutionary  levels  into  which  the  other 
faculties  have  been  divided.  I  call  the  two  groups 
respectively  Subjective  and  Objective,  names  that  have 
been  so  abused  and  are  so  generally  misapplied  that  I 
hesitate  to  use  them,  but  no  others  are  as  appropriate. 

By  a  Subjective  Feeling  I  mean  a  feeling  of  pleasure 
or  pain ;  and  it  is  easy  to  see  that  there  are  several 
grades  or  evolutionary  levels  of  pleasure  and  pain.  On 
the  lowest  level  are  those  crude  pains,  often  miscalled 
bodily  pains,  that  arise  from  structural  damage  to  the 
tissues  of  the  body  and  from  many  functional  disorders. 
Such  are  the  pains  of  wounds  and  burns,  of  colic  and 
cramp,  of  inflammation  and  cancer  ;  the  corresponding 


68  A  TEXT-BOOK  OF  INSANITY 

pleasures  being  those  of  warm  or  cool  and  soft  contact, 
of  stroking  and  rubbing,  of  normal  functions  actively- 
performed.  On  the  second,  or  lower  middle  level,  are 
those  general  and  voluminous  feelings  of  well-being 
or  ill-being,  of  buoyancy  or  depression,  of  high  spirits 
or  low  spirits,  euphoria  or  dysphoria,  that  do  not  admit 
of  analysis,  of  division  into  parts,  or  of  description. 
Everyone  knows  what  they  are  :  everyone  has  experi- 
enced them  at  one  time  or  another.  The  aspect  of  them 
that  is  important  to  the  alienist  is  that  in  the  normal 
they  correspond  with  and  depend  upon  our  estimate 
of  our  circumstances  and  achievements,  as  favourable 
and  successful  or  the  reverse.  If  and  when  circumstances 
are  such  as  to  fulfil  or  favour  our  aspirations,  and 
especially  if  we  are  successfully  approaching  the  achieve- 
ment of  any  task  or  aim,  or  have  actually  just  attained 
it,  then  we  experience  a  feehng  of  elation,  high  spirits, 
and  buoyancy ;  but  when  circumstances  frown  upon 
us  and  oppose  to  our  efiorts  difficulties  that  appear 
insuperable,  or  when  we  recede  from  the  end  we  have 
in  view  instead  of  approaching  it,  or  when  we  fall  short 
or  fail  completely  in  attaining  any  desired  object,  then 
we  experience  depression,  low  spirits,  misery,  in  pro- 
portion to  the  importance  to  our  general  welfare  of  the 
aim  toward  which  we  were  striving.  In  such  circum- 
stances, and  such  being  our  experience,  the  feeling  of 
buoyancy  or  depression  is  justified,  legitimate,  and 
normal  so  long  as  it  is  in  proportion  to  the  importance 
of  the  aim  or  end  concerned  ;  but  when  the  proportion 
is  disturbed  or  faulty,  and  especially  when  the  elation 
or  depression  is  felt  in  the  absence  of  any  justifying 
circumstance  or  experience,  then  it  is  morbid  in  propor- 
tion to  the  width  of  the  discrepancy.  Such  unjustified 
elation  or  depression  is  frequent  enough,  and  is  sane  or 


DYSPHORIA       ,  69 

insane  according  as  it  is  or  is  not  recognised  by  the 
subject  of  it  to  be  unjustified. 

Normally,  the  affection,  that  is  to  say,  the  feehng  of 
elation  or  depression,  is  a  consequence  of  the  circum- 
stances or  the  experience,  and  therefore  follows  the 
appreciation  and  knowledge  of  the  circumstances  or 
experience.  However  adverse  our  circumstances  may 
actually  be,  we  do  not  feel  depression  until  we  know  of 
the  adversity.  Many  of  the  passengers  by  the  ill-fated 
Titanic  did  not  know,  for  an  hour  or  more  after  the 
event,  that  the  ship  had  suffered  such  damage  as  must 
speedily  consign  them  to  a  watery  grave  ;  and  till  that 
knowledge  was  brought  home  to  them  they  were  free 
from  the  depression  that  overwhelmed  them  when  they 
appreciated  the  circumstance.  In  disease,  this  order  is 
frequently,  if  not  invariably,  reversed.  The  depression 
is  felt  first,  and  after  a  longer  or  shorter  interval  some 
circumstance  or  experience  is  imagined  that  would,  if 
it  existed,  justify  and  account  for  the  depression,  and 
this  imagination  speedily  assumes  the  form  of  a  belief, 
which  in  this  instance  is  a  delusion.  In  some  cases  no 
such  imagination  is  formed.  The  depression  is  felt,  but 
no  fictitious  circumstance  is  imagined  to  account  for  it. 
Usually  in  such  cases  when  the  depression  is  deep,  some 
actual  circumstance  or  past  experience  of  an  unfavour- 
able character  is  fixed  upon  as  accounting  for  and 
justifying  the  depression,  but  the  depression  is  out  of 
proportion  and  excessive  with  respect  to  the  experience, 
and  this  excess  may  even  be  recognised  by  the  subject 
of  the  depression.  It  seems,  however,  that  whenever 
depression  is  felt,  there  is  a  very  strong  tendency  to  find 
in  circumstances  or  in  past  experience  a  provocation 
and  justification  for  the  depression  ;  that  some  actual 
circumstance  or  experience  will  be  selected  if  one  caa 


70  A  TEXT-BOOK  OF  INSANITY 

be  found,  and  if  intellect  participates  but  little  in  the 
disorder ;  but  tbat  if,  as  is  usual,  intellect  as  well  as 
Subjective  Feeling  is  disordered,  some  circumstance  or 
experience  of  sufficiently  disastrous  character  will  be 
imagined  and  believed  in  to  account  for  the  depression. 
And  the  same  is  the  case,  mutatis  mutandis,  with 
euphoria  or  exhilaration.  To  take  a  concrete  case  : 
a  man  who  feels  deeply  depressed  will,  if  his  intellect 
remains  unafiected,  or  but  little  affected,  dwell  upon 
some  pecuniary  loss  that  he  suffered  some  time  ago, 
and  that  did  not  greatly  concern  him  at  the  time,  and 
will  worry  and  fret  over  this  loss  as  if  it  were  a  justifica- 
tion for  his  present  depression ;  and  if  he  were  asked 
he  would  say  that  he  is  depressed  because  of  his  loss. 
If,  however,  he  has  had  no  such  loss,  and  if  his  intellect 
participates,  as  it  often  does,  in  the  disorder  of  feeling, 
then  he  will  imagine  disasters,  either  past  or  impending, 
sufficient  to  account  for  the  depression,  and  will  believe 
these  imaginations  represent  the  true  state  of  his  affairs. 
He  has  lost  all  his  money  ;  his  business  is  ruined  ;  his 
wife  has  run  away  from  him  ;  he  has  committed  some 
crime  ;  he  is  the  unpardonable  sinner  ;  or  if  these  things 
have  not  already  happened,  they  are  about  to  happen, 
and  no  effort  of  his  can  avert  them. 

Since,  in  the  normal,  appreciation  of  circumstances 
or  of  experiences,  favourable  or  the  reverse,  always 
precedes  exhilaration  or  depression,  it  is  natural  to 
suppose  that  the  same  order  would  be  followed  in  disease, 
and  that  morbid  exhilaration  and  morbid  depression 
would  always  depend  upon  misappreciation  of  circum- 
stances or  misrecollection  of  experience  :  and  this  view 
is  often  taken  by  alienists.  They  find  depression  or 
exaltation  accompanied  by  a  deluded  belief  in  facts  that, 
if  it  were  true^  would  go  far  to  justify  the  eixhilaration 


.ESTHETIC  PLEASUKE  AND  PAIN        71 

or  depression  ;  and  they  assume  that  the  normal  order 
has  been  followed,  and  that  the  state  of  affective  feeling 
is  a  consequence  of  the  delusion.  Careful  study  of  the 
history  of  such  cases  would  show  them  that  this  is  not 
the  sequence  of  events.  In  every  case  the  history  shows 
that,  where  there  is  an  appreciable  order  in  the  events, 
the  afiective  feeling  alters  first,  and  the  delusion  is 
subsequent  and  consequential. 

Rising  now  from  the  lower  middle  to  the  upper  middle 
level  of  pleasures  and  pains,  we  may  constitute  this  level 
of  the  pleasures  and  pains  of  aesthetics.  On  the  one 
aspect  are  the  pleasures  experienced  in  appreciating 
beauty,  whether  of  form,  of  colour,  or  of  sound,  of 
nature  or  of  art,  and  on  the  other  aspect  are  the  corre- 
sponding pains  produced  by  the  appreciation  of  harsh- 
ness and  ugliness.  How  much  the  appreciation  of 
beauty  and  ugliness  varies  in  difierent  people  is  suffi- 
ciently notorious,  and  it  is  well  known,  though  scarcely 
as  well  recognised,  that  it  varies  very  widely  in  the  same 
person  for  di:Serent  impressions.  Those  who  keenly 
appreciate  beauty  and  ugliness  of  form  are  not  always 
equally  appreciative  of  the  same  qualities  of  colour, 
and  those  who  can  appreciate  both  may  be  very  in- 
appreciative  of  beauty  and  ughness  of  sound. 

To  the  student  of  disorder  of  mind,  these  subjective 
feelings  of  the  upper  middle  level  are  of  httle  impor- 
tance, and  their  disorders  have  attracted  little  attention, 
though  instances  in  which  they  have  sufiered  disorder 
will  not  have  escaped  the  vigilant  student  of  insanity. 
In  a  treatise  like  this,  however,  which  does  not  profess 
to  be  exhaustive,  but  gives  only  a  bare  outline  of  dis- 
orders of  mind,  it  is  unnecessary  to  pursue  further  a 
matter  of  minor  importance. 

The  topmost  level  of  pleasures  and  pains  is  consti- 


72  A  TEXT-BOOK  OF  INSANITY 

tuted  by  those  of  the  moral  order,  or  what  is  much  the 
same  thing,  those  that  arise  out  of  our  social  circum- 
stances and  the  fulfilment  or  neglect  of  our  social 
obligations.  On  the  active  side  there  is  the  pleasure 
of  duty  well  done,  of  happiness  conferred,  of  services 
rendered,  of  benefits  bestowed,  with  the  corresponding 
pain  of  remorse  for  abstention  and  neglect,  and  it  may 
be,  alas  !  for  active  misdeeds  ;  on  the  passive  side  are 
the  pleasures  of  receiving  approbation  and  applause, 
the  signs  of  being  liked,  respected,  admired,  with  the 
corresponding  pains  of  receiving  the  marks  of  disappro- 
bation and  reproof,  of  being  disliked  and  despised. 

The  subjective  feelings  share  in  the  general  degrada- 
tion of  mind  that  takes  place  in  many  cases  of  insanity, 
and  not  infrequently  the  whole  of  the  topmost  level 
of  pleasures  and  pains  is  completely  wiped  out ;  indeed, 
it  is  the  rule  in  insanity  that  these  mental  qualities, 
which  are  among  the  last  to  be  acquired,  both  in  the 
race  and  in  the  individual,  are  among  the  first  to  suffer 
diminution  and  obliteration  in  the  dissolution  of  insanity. 
Duties  are  neglected,  the  welfare  of  others  is  regarded 
with  indifference,  occasions  of  conferring  benefit, 
especially  those  trifling  but  valued  benefits  that  ordinary 
politeness  and  good  breeding  dictate,  are  ignored, 
without  any  remorse  or  regret  following  the  omission ; 
and  correspondingly  there  is  no  sensibility  to  either 
approbation  or  reprobation,  to  applause  or  reproof  ; 
and  the  tributes  of  love  and  admiration  no  more  arouse 
pleasure  than  the  expression  of  dislike  and  contempt 
excite  pain. 

It  happens  often  enough  that  the  pleasures  and  pains 
of  the  moral  level  are  experienced  inappropriately, 
when  there  is  no  justification  for  them  in  the  experience 
of  the  person  who  feels  them ;   but  in  such  cases  the 


OBJECTIVE  FEELING  73 

disorder  is  not  in  the  faculty  of  feeling,  which  faithfully 
responds  to  the  information  it  receives  from  intellect. 
When  remorse  is  felt  for  sins  that  have  never  been 
committed,  when  complacency  is  felt  at  liking  and 
approbation  that  have  never  been  expressed  or  felt, 
what  is  at  fault  is  not  the  feeling,  but  the  belief  to 
which  the  feeling  responds.  If  the  information  that 
reaches  the  Faculty  of  feeling  were  correct,  if  the  sin 
really  had  been  committed,  or  the  applause  or  token  of 
afiection  really  had  been  received,  the  corresponding 
feeling  of  remorse  or  complacency  would  be  justified 
and  normal.  Feeling  acts  normally  on  the  information 
supplied  to  it,  and  if  the  information  is  erroneous,  the 
fault  lies  at  the  door  of  intellect,  which  supplies  it,  not 
of  feeling,  which  does  the  best  it  can  with  the  material 
at  its  disposal. 

FEELING  II.      OBJECTIVE 

By  Objective  Feehngs  I  mean  the  residue  that 
remains  of  compound  feehngs  when  the  pleasure  or 
pain  that  accompanies  them,  or  enters  into  their  com- 
position, is  abstracted  and  removed.  In  actual  ex- 
perience, the  pleasure  or  the  pain  is  in  many  cases 
inseparable  from  the  rest  of  the  feeling,  is  in  many 
cases  an  integral  component  of  the  feeling ;  but  in 
many  cases  also  some  element  of  thought,  or  desire,  or 
will  enters  into  a  complex  mental  state,  and  yet  we  have 
no  difficulty  in  abstracting  that  element  and  giving  to  it 
a  separate  consideration,  as  if  it  occurred  alone  ;  and 
there  is  no  more  difficulty  in  disregarding  the  pleasure  or 
pain  of  an  emotion,  and  contemplating  separately  the 
other  constituents  of  the  compound  mental  state  so 
denominated,  than  in  disregarding  the  reasons  why  we 


74  A  TEXT-BOOK  OF  INSANITY 

come  to  a  certain  determination,  and  fixing  our  attention 
on  the  determination  alone. 

All  feelings  are  identified  more  or  less  completely  witli 
the  Self,  or  the  subjective  side  of  mind,  but  with  the 
feelings  of  pleasure  and  pain  the  identification  is 
especially  close  and  inseparable,  and  therefore  to  them 
the  title  of  Subjective  applies  with  great  appropriateness. 
The  feelings  of  the  present  class,  which  I  call  in  contrast 
Objective,  are  slightly  more  detachable,  and  although 
the  term  must  appear  a  contradiction,  it  may  perhaps 
be  allowed  to  pass. 

The  lowest  level  of  Objective  Feelings  is  occupied  by 
Sensations.  By  a  sensation  we  understand  a  state 
arising  in  the  mind  in  response  to  an  impression  received, 
a  quasi-passive  state,  into  the  composition  of  which  no 
responsive  activity  of  mind  enters.  When  a  sensation 
is  received  or  aroused  in  the  mind,  a  responsive  activity 
does  in  fact  take  place.  The  mind  seizes  upon  the 
new  content  and  elaborates  it  into  something  more 
than  a  sensation,  as  we  shall  presently  find  ;  but  for  the 
purpose  of  description  and  of  understanding  the  com- 
position of  the  mind,  it  is  necessary  to  analyse  its 
processes  and  make  distinctions  that  are  to  a  certain 
extent  arbitrary.  One  of  the  least  arbitrary  of  these 
distinctions  is  the  separation  of  sensation  from  percep- 
tion. Sensations  are  divided  according  as  they  are  or 
are  not  brought  into  being  by  bodily  activity  ;  and  the 
latter  class  according  to  the  sense  organ  by  which  the 
impression  is  received.  The  sensations  that  are  pre- 
ceded or  accompanied  by  bodily  activity  to  which  they 
owe  their  existence  are  those  of  Eesistance  and  Freedom 
and  of  Effort.  The  sensations  of  the  passive  order  are 
the  Visual,  including  Light  and  Colour,  the  Auditory, 
the  Tactile;  the  Olfactory,  the  Gustatory,  the  Sense  of 


EMOTION  75 

Temperature,  and  perhaps  some  others.  The  whole 
realm  of  sensation,  together  with  its  disorders,  is  in  the 
province  of  the  physiologist  and  the  physician,  and  has 
no  bearing  on  the  work  of  the  alienist.  It  is  a  very 
large  and  a  very  interesting  field,  and  is  cultivated 
with  much  assiduity  in  most  books  on  Psychology,  but 
it  need  not  be  traversed  here. 

The  two  middle  levels  of  Objective  Feelings  are 
occupied  by  the  emotions,  divested  of  their  ingredient  of 
pleasure  or  pain.  An  emotion  is  a  mental  state  of 
considerable  complexity,  and  has  been  analysed  with 
great  skill  by  William  James  and  others  ;  but  the 
composition  of  emotions  is  not  a  matter  of  any  concern 
to  the  alienist,  and  there  is  no  need  to  examine  it  here. 
What  the  alienist  is  concerned  with  is  the  circumstances 
under  which  emotions  normally  arise  in  the  mind,  and 
the  alterations  that  occur  in  disease  in  the  relations 
between  emotions  and  circumstances.  In  my  book  on  the 
Nervous  System  and  the  Mind  is  an  elaborate  classifica- 
tion of  Feelings,  and  amongst  them  of  Emotions,  based 
upon  the  difierences  in  the  circumstances  that  normally 
call  them  forth.  Anyone  who  is  sufficiently  interested 
in  the  subject  will  there  find  a  complete  enumeration 
of  the  emotions,  together  with  a  description  of  the 
circumstances  in  which  they  severally  arise  ;  but  such 
a  complete  enumeration  is  not  needed  in  such  a  mere 
outline  as  this.  All  that  is  necessary  for  the  student  of 
alienism  to  bear  in  mind  is  that  every  emotion  is  aroused 
by  a  certain  appropriate  circumstance,  which  must  be 
cognised  and  appreciated  by  the  intellect  before  the 
emotion  can  come  into  being  ;  and  that  emotions  may 
be  broadly  divided  into  two  groups,  one  of  which  is 
aroused  by  circumstances,  or  events  or  experiences  that 
are,  or  are  believed  to  be,  antagonistic  or  beneficejat 


76  A  TEXT-BOOK  OF  INSANITY 

towards  the  person,  or  towards  others  with  whom  he 
is  iu  relation,  while  the  emotions  of  the  other  group  are 
aroused  by  circumstances  and  experiences  that  are 
neutral  in  this  respect.  The  first  group,  consisting  of 
the  Emotions  of  Antagonism,  Repugnance,  and  Kindli- 
ness, and  including  such  emotions  as  Anger,  Fear, 
Triumph,  Contempt,  Disgust,  Horror,  Anxiety,  Sorrow, 
Joy,  and  their  associates  and  congeners,  I  place  on  the 
lower  middle  level ;  the  upper  middle  level  of  Objective 
Feelings  being  constituted  by  the  ^Esthetic  Sentiments 
of  Admiration,  Awe,  Wonder,  Surprise,  and  so  forth, 
which  are  called  forth  by  circumstances  and  experiences 
that  have  no  direct  effect  on  the  welfare  either  of  the 
subject  himself  or  of  those  with  whom  he  is  in  relation. 
The  topmost  level  of  Objective  Feelings  is  occupied  by 
those  which  are  aroused  exclusively  by  social  circum- 
stances and  experiences,  and  which  comprise  the  feelings 
of  Approbation  and  Reprobation,  Pride,  Dignity,  Shame, 
Guilt,  Martyrdom,  Sympathy,  Pity,  Benevolence,  and  so 
forth,  in  as  far  as  these  feelings  can  exist  free  from  the 
pleasure  or  pain  which  enters  so  largely  into  their 
composition. 

Disorder  of  any  of  these  feelings  exists  when  the 
feeling  is  entertained  apart  from  the  special  circum- 
stance or  experience  which  normally  calls  it  forth  and 
justifies  it ;  and  disorder  of  less  degree  exists  when  the 
emotion  is  out  of  proportion  to  the  justifying  experience 
or  circumstance.  Fear,  for  instance,  should  normally 
arise  only  when  we  are  threatened  with  injury  by  some 
agent  superior  in  power  to  ourselves  ;  and  in  order  for 
fear  to  be  justified  there  should  be  no  mistake  in  our 
estimate.  It  should  be  a  fact  that  we  are  threatened, 
and  that  we  are  threatened  by  an  agent  of  power 
superior  to  our  own,  and  if  these  two  conditions  are 


DISORDER  OF  EMOTION  77 

fulfilled,  tlie  emotion  is  a  normal  emotion.  It  may  be, 
however,  that  we  have  made  a  mistake — that  we  are 
not  really  threatened,  or  that  if  we  are,  we  can  easily 
evade  or  antagonise  the  action  that  is  threatened,  and  in 
this  case  the  emotion  is  unjustified,  but  it  is  not  neces- 
sarily disordered.  It  is  not  disordered  if  the  mistake 
can  be  corrected  upon  trial,  or  upon  other  sufficient 
evidence.  If,  however,  fear  is  still  felt  when  there  is  no 
antagonistic  agent,  or  no  threat,  or  if  the  threat  is 
manifestly  idle,  then  there  is  disorder.  It  may  be  that 
the  agent  is  purely  imaginary  ;  or  that,  a  real  agent 
existing,  its  antagonism  and  threatening  are  imaginary  ; 
or  that  a  real  agent,  actually  antagonistic  and  threaten- 
ing, its  power  of  harm  is  imaginary,  as  when  an  earwig 
cocks  up  its  tail ;  in  either  case,  and  especially  in  the 
former,  there  is  disorder,  but  in  all  these  cases  the  dis- 
order is  manifestly  not  disorder  of  emotion,  which 
faithfully  follows  the  facts  as  the  facts  are  supposed  to 
be.  The  disorder  is  in  the  intellect,  which  chooses  to 
misapprehend  the  circumstances,  and  to  give  to  emotion 
a  false  representation  of  them.  It  sometimes  happens, 
however,  that  fear,  anger,  or  some  other  emotion 
arises  in  force  without  the  excuse  of  even  an  imaginary 
circumstance  to  justify  it,  and  in  such  a  case  it  is 
emotion  itself  that  is  disordered.  Both  kinds  of  disorder 
occur,  but  in  the  majority  of  cases  there  is  an  erroneous 
belief  as  to  the  facts,  and  if  the  facts  were  as  they  are 
erroneously  or  deludedly  beUeved  to  be,  the  emotion 
would  be  justified.  Even  in  these  cases,  however,  it  does 
not  follow  that  the  mistake  or  the  delusion  as  to  the 
facts  is  the  first  event  in  the  order  of  time.  Not  in- 
frequently it  can  be  found  that  an  unreasonable  and 
unjustified  emotion  of  fear,  or  anger,  or  what  not,  was 
first    experienced,     and     that    subsequently    circum- 


78  A  TEXT-BOOK  OF  INSANITY 

stances  were  imagined  to  fit  in  with  and  justify  the 
emotion. 

The  whole  Faculty  or  group  of  Feelings  may  be 
stated  in  tabular  form  thus  : — 

FEELINGS 

Subjective  (Pleasure  and  Pain).  Objective. 

Moral.  Moral  Sentiments. 

iEsthetic.  Esthetic  Sentiments. 

Euphoric  and  Dysphoric.  Emotion. 

Crude.  Sensation. 


INTELLECT  OR  THOUGHT 

The  word  Thought,  like  innumerable  other  words  in  the 
English  language,  is  used  in  two  senses,  as  a  verb,  to 
mean  the  doing  of  a  thing,  and  as  a  noun,  to  indicate  the 
thing  done.  It  may  mean  the  process  or  operation  of 
thinking,  or  it  may  mean  the  result  of  this  process,  the 
thought  that  results  from  the  operation.  With  the 
process  of  thought  the  alienist  is  not  much  concerned, 
and  in  fact  no  allusion  whatever  is  made,  to  my  know- 
ledge, in  any  book  on  insanity  to  error  or  disorder  of  the 
process  of  thought.  This  is  not  because  such  errors  or 
disorders  are  infrequent  in  insanity,  for  in  fact  they  are 
frequent  enough.  The  attention  of  alienists  has  been 
concentrated  upon  Belief,  one  of  the  results  of  thought, 
and  it  does  not  seem  to  have  occurred  to  them  that  if 
the  result  is  erroneous,  the  cause  is  to  be  sought  in  error 
of  the  process  that  leads  to  this  result.  This  is  probably 
because  the  process  of  thought  is  transient  and  cannot 
be  easily  traced,  while  the  belief  that  results  from  it  is 
enduring,  and  is  usually  as  easy  to  identify  and  examine 
as  the  process  is  difficult;  and  in  the  second  place 


INTELLECT  OR  THOUGHT  79 

because  the  process  of  reasoning  has  been  completely 
misunderstood,  and  the  only  description  of  it  that  has 
been  at  the  service  of  alienists  has  been  the  crude, 
erroneous,  and  imperfect  description  of  Aristotle,  which 
is  ludicrously  inadequate  and  ineffectual. 

The  true  reason  for  the  superior  importance  that  has 
always  been  attached  by  alienists  to  disorders  of  belief 
or  delusion  is  that  upon  belief  all  conduct  is  founded ; 
and  although  alienists  have  neglected  and  scorned 
the  systematic  study  of  conduct,  and  although  they 
refuse  to  admit  in  words  that  insanity  is  primarily  dis- 
order of  conduct,  yet  conduct  is  so  manifestly  of  para- 
mount importance  in  insanity  that  a  blind  but  sure 
instinct  has  compelled  them  to  pay  special  attention  to 
that  factor  in  mind  by  which  conduct  is  mainly  guided. 
Every  act  of  every  human  being  is  determined  by  belief. 
We  should  not  walk  across  a  room  to  get  a  book  unless 
we  believed  that  the  book  was  at  the  other  side  of  the 
room,  and  that  the  floor  would  bear  our  weight. 

There  is  another  good  reason  why  the  intellect  should 
have  been  looked  upon  as  of  paramount  importance  in 
insanity,  a  reason  which  has  never  been  formulated  or 
discovered  by  any  alienist,  but  which  in  some  dim  and 
inchoate  form  has  probably  been  at  the  back  of  their 
minds.  This  is  that  disorder  or  defect  of  the  highest 
level  of  intellect  is  a  necessary  ingredient  in  insanity. 
Mind  may  be  disordered  in  any  faculty  and  on  any  level 
of  any  faculty,  but  unless  the  disorder  implicates  the 
highest  level  of  thought,  objective  or  subjective,  this 
disorder  of  mind  is  sane  and  not  insane.  It  is  by  virtue 
of  the  highest  level  of  thought  that  we  recognise  and 
gauge  our  own  mistakes  and  disorders,  and  as  long  as 
this  highest  level  is  intact,  so  that  we  can  and  do  recog- 
nise that  our  mistakes  are  mistakes,  and  our  disorders, 


80  A  TEXT-BOOK  OF  INSANITY 

whether  of  mind  or  conduct,  are  disorders,  so  long 
sanity  is  unafiected,  and  our  mistakes  and  disorders  are 
sane.  As  soon,  however,  as  we  become  incompetent  to 
make  this  adjustment,  and  proceed  to  act  on  the  supposi- 
tion that  our  disordered  mental  processes  and  states  are 
valid  and  correct,  and  make  no  attempt  to  correct  our 
mistakes,  the  Kubicon  is  passed,  sanity  is  left  behind, 
and  insanity  is  established. 

It  is  not  on  this  account,  however,  that  alienists  have 
confined  their  study  of  the  disorders  of  mind  exclusively 
to  disorders  of  thought.  It  is  because  disorders  of 
thought  are  so  conspicuous,  dramatic,  and  impressive, 
that  it  was  for  long  held  universally,  and  is  still  held  by 
some,  that  the  disordered  belief  that  is  termed  delusion 
is  the  only  disorder  of  mind,  and  is  co-extensive  with 
insanity.  Delusion  was  for  long  the  sole  criterion  of 
insanity:  without  delusion  there  was  no  insanity;  and  an 
insane  person  meant  a  deluded  person  and  no  one  else. 
Once  held  universally,  and  formally  laid  down  in  Courts 
of  Law,  this  doctrine  still  lingers,  not  only  amongst  the 
laity,  but  even  amongst  medical  practitioners,  some  of 
whom  to  this  day  refuse  to  certify  a  person  as  insane 
unless  they  can  discover  in  him  evidence  of  delusion. 
This  long  identification  of  insanity  with  delusion  was 
no  doubt  largely  answerable  for  the  blunder,  which 
should  now  be  considered  an  anachronism  as  well  as  an 
absurdity,  of  identifying  insanity  with  unsoundness  of 
mind. 

To  give  here  a  complete  account  of  the  normal  process 
of  reasoning  and  of  the  normal  conditions  of  belief  would 
be  to  interpolate  a  treatise  on  Logic  and  a  treatise  on 
Epistemology  ;  and  although  either  would  be  of  more 
value  to  the  alienist  than  learning  to  fiddle  with  the 
ergograph,  and  the  other  instruments  that  make  up  the 


INTELLECT  OE  THOUGHT  81 

armentarmm  of  tlie  ''  experimental  psychologist,"  and 
although  an  alienist  can  scarcely  be  considered  expert 
in  his  profession  without  some  knowledge  of  both,  yet 
their  direct  bearing  upon  the  study  of  individual  cases 
of  insanity  and  other  mental  disorders  is  not  sufficient 
to  warrant  the  space  being  given  to  them  here.  Those 
who  wish  to  follow  up  this  line  of  study  should  read 
"  A  New  Logic  "  and  the  sections  on  Truth,  Certainty, 
Likelihood,  etc.,  in  my  book  on  Psychology. 

Intellect  has  two  sides,  of  which  one  only  has  hitherto 
been  recognised.  By  means  of  Intellect  or  Thought  we 
judge  or  estimate  the  nature  and  bearings  of  our  sur- 
rounding circumstances,  and  devise  methods  of  dealing 
with  them  in  such  ways  as  to  turn  them  to  our  advan- 
tage. This  is  the  external  or  objective  side  of  intellect, 
and  it  is  the  only  aspect  of  intellect  that  has  received 
any  attention,  or  is  recognised  or  known  to  psychologists. 
But  there  is  another  side  to  intellect,  and  one  that  is 
of  the  utmost  importance  to  the  alienist,  for  it  is  the 
seat  of  frequent  and  grave  disorder.  By  means  of 
intellect  we  judge  not  only  of  external  circumstances, 
but  of  our  own  powers  and  capacities  and  other  quahties  ; 
and  a  moment's  consideration  will  show  that  in  dealing 
with  circumstances,  and  in  devising  methods  of  dealing 
with  circumstances,  it  is  quite  as  important  to  form  a 
just  estimate  of  our  own  powers  as  to  judge  accurately 
of  the  circumstances  without.  If  I  find  an  obstacle  in 
my  way,  it  is  important  to  discover  its  nature,  and  its 
mobihty  or  immobility ;  but  it  is  evident  that  its  mo- 
bihty  or  immobility  is  relative  to  my  own  strength. 
What  I  mean  by  the  mobihty  or  immobility  of  the 
obstacle  is  whether  I  have  or  have  not  the  strength  to 
move  it ;  and  it  is  evident  that  what  appears  to  be  a 
quality  in  the  obstacle  is  really  dependent  on  a  quahty 


82  A  TEXT-BOOK  OF  INSANITY 

of  my  own.  If  I  liave  to  catch  a  train,  it  is  very  neces- 
sary that  I  should  estimate  the  distance  of  the  station 
and  the  time  at  my  disposal ;  but  these  are  no  use  to  me, 
however  accurately  I  may  estimate  them,  unless  I 
estimate  also  the  rate  at  which  I  can  walk  or  run.  It  is 
impossible  to  deal  with  circumstances,  or  to  devise  ways 
of  dealing  with  circumstances,  unless  we  take  into  con- 
sideration and  estimate  our  own  powers  and  capacities. 
This  side  of  intellect,  which  I  call  the  Subjective  side, 
does  not  appear  to  have  been  discovered  by  psycholo- 
gists, but  the  disorder  that  it  frequently  sufiers 
makes  it  very  conspicuous  to  the  alienist,  and  very 
important  to  him.  I  therefore  treat  of  Intellect  on  two 
aspects  ;  first  the  Objective  aspect,  or  the  Estimation  of 
Circumstances,  and  second  the  Subjective  aspect,  or 
Self-estimation. 


OBJECTIVE   INTELLECT 

There  are  three  processes  of  Reasoning,  two  of  which, 
or  rather  parts  of  two  of  which,  are  known,  very 
imperfectly,  to  Logicians.  They  are  Induction,  Deduc- 
tion, and  Analogy,  but  the  last  two  of  these  may  be 
neglected,  for  neither  of  them  leads  directly  to  Belief,  and 
therefore  neither  is  of  direct  importance  to  conduct. 
Induction  is  the  reasoning  process  with  which  the 
alienist  is  most  concerned,  and  fortunately  for  him  the 
process  of  Induction  is  a  simple  one.  Induction  rests 
upon  this  simple  principle — that  if  two  things  resemble 
each  other  in  some  material  respects,  they  will  resemble 
each  other  in  other  material  respects  ;  or  to  put  it  other- 
wise, if  two  things  have  certain  qualities  in  common, 
they  will  have  in  common  certain  other  qualities  that 
have  been  found  in  experience  in  constant  association 


OBJECTIVE  INTELLECT  83 

with,  or  to  depend  upon,  the  first  common  qualities. 
For  instance,  if  a  certain  fruit  resembles  in  material 
respects  another  fruit  that  has  been  found  in  experience 
always  wholesome  or  always  poisonous,  the  first  fruit 
will  be  found  wholesome  or  poisonous  as  the  case  may 
be.  "What  respects  are  material  cannot  be  stated  gener- 
ally. That  is  a  matter  for  experience  in  each  case  as  it 
arises  ;  but  granted  that  there  is  similarity  in  material 
respects,  the  induction  will  be  sound  and  the  resulting 
belief  justified. 

The  simplest  beliefs  result  from  those  simple  inductions 
that  are,  as  it  were,  forced  upon  us  by  sensation.  The 
sensation  of  a  small  patch  of  brown  colour  on  the  green 
grass  arrests  my  attention,  and  instantly  arouses  the 
remembrance  of  innumerable  patches,  similar  in 
material  respects,  that  I  have  seen  before.  These  other 
patches  of  colour  I  have  found  in  experience  to  possess 
certain  qualities.  I  have  submitted  them  to  examina- 
tion by  various  senses,  and  have  found  that  they  indicate 
thin,  brittle,  light,  fragrant,  rustHng  laminse,  that  they 
are  in  fact  dead  leaves  ;  and  I  reason  or  induce  that  this 
new  patch  that  I  see  before  me,  since  it  is  similar  in  the 
material  respects  of  light  and  shade  and  outline  and 
mobility  in  the  wind,  is  similar  in  other  material  respects 
also,  and  would,  if  I  examined  it  closely,  prove  to  be  a 
thin,  brittle,  light,  fragrant,  rustling  lamina,  similar  to 
others  that  I  see  hanging  on  the  tree.  The  result  of  this 
induction  is  the  belief  that  this  patch  of  colour  represents 
a  dead  leaf,  and  beliefs  of  this  class,  that  are  initiated, 
and  in  a  measure  forced  upon  us,  by  an  impression  on 
the  senses,  are  called  Percepts  ;  and  the  process  of 
induction  by  which  they  are  reached  is  called  Perception. 
The  process  is  the  simplest  and  most  rapid  instance  of 
induction — is  so  simple  and  so  rapid  that  its  nature  is 


84  A  TEXT-BOOK  OF  INSANITY 

obscured,  and  by  most  psychologists  it  is  considered  not 
to  be  induction  ;  but  this  is  merely  an  instance  of  the 
familiar  fact  that  wide  superficial  differences  often  conceal 
a  deep  and  fundamental  similarity  or  identity.  Percepts 
vary,  of  course,  according  as  the  sensation  that  initiates 
them  is  visual,  auditory,  tactual,  or  what  not,  but  all 
are  arrived  at  by  the  same  simple  process,  and  all  are 
beliefs  of  the  same  simple  character. 

The  process  of  perception  may  be  ill-performed,  and 
the  resulting  belief  may  be  erroneous ;  and  in  this  case 
the  error  may  be  corrigible  or  incorrigible — sane  or 
insane.  Mistakes  in  perception  of  greater  or  less  degree 
are  not  very  infrequent.  We  see  an  aneroid  barometer 
of  the  shape  and  size  of  a  watch,  and  on  a  casual  glance 
we  perceive  that  it  is  a  watch.  The  percept  is  a  mistake. 
The  belief  is  erroneous.  Such  a  belief  is,  however, 
corrigible.  If  we  examine  the  thing  more  attentively, 
we  shall  perceive  that  it  is  not  a  watch,  and  if  we  are 
already  familiar  with  barometers  we  shall  perceive  that 
it  is  an  aneroid. 

Graver  mistakes  are  frequent  in  disease.  In  some 
states  of  disease,  a  man  seeing  a  piece  of  string  lying  on 
the  floor,  will  read  into  it  the  qualities  of  a  worm  or  a 
snake.  He  will  perceive  it,  not  as  a  piece  of  string,  but 
as  a  worm  or  a  snake  ;  and  this  percept  may  be  cor- 
rigible or  incorrigible.  If  he  has  the  courage  and  pre- 
sence of  mind  to  pick  it  up  and  examine  it  attentively, 
he  may  correct  his  percept  and  arrive  at  the  valid 
belief  that  it  is  a  piece  of  string  ;  or  he  may  be  unable  to 
make  the  correction,  and  still  perceive  it  as  a  snake.  In 
the  first  case  the  mistake  is  a  sane  mistake,  and  is  an 
example  of  a  sane  disorder  of  mind  that  is  by  no  means 
infrequent.  In  the  latter  case  the  mistake,  being  in- 
corrigible,  is    insane,    and   is   an    example   of   insane 


DISORDERS   OF  PERCEPTION  85 

illusion,  an  insane  disorder  of  mind  that  is  frequent 
enough. 

Similar  mistakes  occur  in  interpreting  or  perceiving 
auditory  sensations.  We  hear  a  voice,  and  perceive  that 
it  is  the  voice  of  A.  It  is  in  fact  the  voice  of  B  ;  and  if  B 
is  before  us  and  we  see  as  well  as  hear  him  speaking,  we 
may  be  able  to  correct  the  process  and  arrive  at  the 
valid  belief  that  we  had  been  mistaken,  and  that  the 
voice  was  in  fact  the  voice  of  B.  If,  however,  we  cannot 
make  the  correction,  but  continue  to  beheve  that  B  is 
speaking  with  the  voice  of  A,  the  belief  is  no  longer  sane. 
It  is  an  insane  illusion.  Still  graver  is  the  disorder  when 
some  inarticulate  sound,  such  as  the  song  of  birds  or 
the  wind  in  the  trees,  is  perceived  as  spoken  words. 
In  such  a  case  the  mistake  is  nearly  always  incorrigible, 
and  the  illusion  is  therefore  insane. 

A  still  wider  departure  from  the  normal  takes  place 
when  a  percept  is  perceived  without  any  provocation  or 
basis  in  the  shape  of  a  sense  impression  to  justify  it,  or 
any  percept.  Whether  such  an  event  ever  really  takes 
place  I  take  leave  to  doubt.  The  sense  organs  are 
never  wholly  free  from  stimuli,  internal  or  external. 
Even  in  the  dark  and  with  closed  eyes  we  see  clouds  and 
rings  of  colour.  Even  in  the  silence  of  the  dead  of  night 
we  hear  the  rush  of  blood  in  the  cerebral  arteries  ;  and  a 
very  trifling  sense  impression  is  enough  to  form  the 
nucleus  of  a  percept  in  certain  morbid  states  of  mind. 
However,  whether  this  is  so  or  not,  it  is  manifestly  a 
wider  departure  from  the  normal  to  found  a  percept  on 
a  sensation,  if  sensation  there  be,  that  no  one  else  can 
appreciate,  than  on  one  of  a  grosser  character  ;  and 
percepts  of  this  nature  are  distinguished  from  other 
illusions  and  receive  the  title  of  hallucinations. 

Perception  is  the  most  rudimentary  process  of  thought, 


86  A  TEXT-BOOK  OF  INSANITY 

or  intellect,  and  Percepts  are  the  simplest  of  Beliefs. 
These  then  constitute  the  lowest  level  of  Objective 
Intellect. 

The  next  step  upwards  in  Objective  Intellect  after 
perceiving  an  object  is  to  form  an  estimate  of  the 
beneficence,  the  maleficence,  or  the  neutrality  of  that 
object  with  respect  to  one's  own  life-worthiness  or 
welfare.  The  lowest  and  most  rudimentary  process  of 
thought  answers  the  question.  What  is  this  ?  What 
manner  of  object  is  it  that  produces  this  impression  on 
my  senses  ?  Immediately  following  the  determination 
of  this  problem  comes  the  further  question.  Now  that  I 
know  what  this  object  is,  is  it  potentially  harmful  or 
beneficial  to  me  ?  Is  it  dangerous,  and  in  what  way  ? 
Can  I  utilise  it,  and  in  what  way  ?  The  estimation  of 
beneficence  or  maleficence  is  often  almost  as  instan- 
taneous as  perception  itself  ;  but  it  is  difierent  from  the 
perception,  and  the  difierence  is  well  brought  out  by 
the  discrimination  of  disease.  A  housewife  who  has  had 
abundant  experience  of  the  kettle  and  the  wash  tub, 
and  whose  experience  of  the  destructive  and  painful 
effect  of  boiling  water  on  the  skin  is  ample,  becomes 
demented  to  a  certain  depth,  such  that  while  she  retains 
the  power  of  perception,  and  can  perceive  that  the  vessel 
before  her  contains  water,  and  by  the  abundant  steam 
that  rises  from  it,  scalding  water,  yet  has  lost  her  power 
of  estimating  the  harmful  quality  of  scalding  water,  and 
immerses  her  hand  in  it,  well  perceiving  that  it  is 
scalding  hot,  but  not  estimating  that  it  has  the  power  to 
scald.  Similarly,  a  man  accustomed  to  the  traffic  of  the 
streets  may  perceive  that  the  object  which  approaches 
him  is  a  two-horse  van,  but  he  fails  to  estimate  that  this 
object  possesses  lethal  qualities,  so  that  if  he  gets  in  its 
way  it  will  knock  him  down  and  injure  him.    This  power 


DISORDER  OF  CAUTION  87 

of  estimating  tlie  harmful  or  benej&cial  quality  of 
perceived  objects  or  appreciated  circumstances  I  call 
for  want  of  a  better  title,  Caution.  Thus  characterised, 
the  power  or  process  of  estimating  the  beneficial  or 
harmful  quality  of  familiar  objects  constitutes  the 
lower  middle  level  of  Objective  Thought. 

Defect  of  caution  is  not  the  only  disorder  of  the  lower 
middle  level  of  thought.  A  frequent  disorder  of  this 
level  is  an  exaggerated  estimate  of  the  potential  noxious- 
ness and  maleficence  of  surrounding  agents,  an  esti- 
mate that  results  in  a  general  attitude  of  suspicion.  The 
estimate  may  be  thus  general,  or  it  may  be  concen- 
trated upon  certain  specific  things  or  persons.  The  most 
exaggerated  instances  are  seen  in  the  disease  of  paranoia, 
of  which  exaggerated  and  unreasonable  suspicion, 
unjustified  by  circumstances,  is  one  of  the  most  promi- 
nent features.  Usually  in  paranoia  there  is  more  than 
suspicion  :  there  is  settled  and  deep  conviction  of  the 
hostility  and  noxiousness  of  some  one  or  more  persons, 
who  may  be  real  or  may  be  imaginary,  but  in  any  case 
the  settled  belief  in  the  noxiousness  and  hostihty  of  this 
person  or  of  these  persons  is  but  the  nucleus  of  a  cloud 
of  suspicion  that  spreads  far  beyond  them,  and  is  apt  to 
become  almost  universal.  The  most  innocent  acts  of 
the  most  utter  strangers  are  enveloped  in  the  suspicion. 
The  casual  greetings  of  strangers  in  the  street,  the  pubHc 
utterances  of  public  men,  the  leading  articles  in  news- 
papers, are  all  suspected ;  and  subtle  references,  ofiensive 
references,  to  the  suspicious  person  are  found  in  them 
all. 

The  upper  middle  level  is  constituted  by  inductions  of 
a  more  elaborate  character,  dealing  with  more  general 
circumstances,  and  may  fitly  be  represented  here  by  the 
means  which  are  devised  to  meet  circumstances  whose 


88  A  TEXT-BOOK  OF  INSANITY 

quality,  as  beneficial  or  otherwise,  lias  been  determined 
on  the  level  below.  This  faculty,  which  we  may  term 
Ingenuity  or  Cleverness,  takes  cognisance  not  of  mere 
objects  that  can  be  seen,  heard,  or  touched,  but  of 
whole  situations,  constituted  by  a  complete  set  of 
circumstances,  such,  for  instance,  as  those  embodied  in 
the  terms  of  an  agreement,  the  lease  of  a  house,  or  a  deed 
of  partnership.  Caution  advises  us  that  our  informant 
is  not  trustworthy,  and  ingenuity  sets  to  work  to  sift 
his  information  and  compare  it  with  that  from  other 
sources.  Caution  tells  us  that  a  storm  is  imminent 
and  ingenuity  looks  about  for  shelter.  Caution  shows 
us  the  danger  of  a  conflagration,  ingenuity  devises  means 
to  prevent  and  to  extinguish  it. 

The  highest  level  of  Objective  Intellect  is  the  faculty 
of  Wisdom,  which  estimates  by  and  large  the  important 
circumstances  of  life,  and  thinks  out  what  our  conduct 
should  be  in  order  to  secure  the  main  purposes  of  life. 
If  ingenuity  settles  the  terms  of  an  agreement,  wisdom 
determines  whether  an  agreement  shall  be  made  or  no. 
Ingenuity  may  settle  the  terms  of  a  lease,  but  wisdom 
decides  whether  or  no  the  house  shall  be  taken.  In- 
genuity governs  the  clauses  of  the  partnership  deed, 
but  wisdom  decides  whether  or  not  it  is  expedient  to 
enter  into  the  partnership.  Shall  I  make  a  public 
proclamation  of  my  opinion  and  attitude  on  this  vital 
question  ?  Wisdom  ponders  the  pros  and  cons,  and 
lays  them  before  the  highest  level  of  Will  for  determina- 
tion. Cleverness  or  ingenuity  devises  the  method  by 
which  the  position  is  to  be  stated.  Caution  estimates 
the  appropriateness  of  the  words  and  phrases.  Percep- 
tion sees  to  the  spelling.  Or  we  may  illustrate  the 
several  levels  thus  :  Ought  I  in  these  circumstances  to 
bring  an  action  at  law  ?    Wisdom,  in  the  person  of 


WISDOM  AND  INGENUITY  89 

counsel,  gives  tlie  opinion.  That  being  decided,  In- 
genuity, in  the  person  of  the  solicitor,  takes  the  proofs 
of  the  chief  witnesses  and  devises  the  means  for  putting 
the  decision  into  force.  His  clerk,  who  represents 
Caution,  sees  the  formal  witnesses  and  attends  to 
details  ;  and  the  office  boy,  who  personifies  the  lowest 
level,  takes  the  names  of  the  witnesses  and  shows  them 
in.  Shall  I  or  shall  I  not  go  to  that  place  1  Wisdom 
discusses  the  alternatives.  How  shall  I  get  there  ? 
Ingenuity  finds  the  way.  Shall  I  go  by  train  or  motor? 
Caution  dictates  the  choice.  Is  that  a  taxi  or  a  private 
carriage  ?  Perception  makes  the  judgment.  Wisdom 
settles  the  strategy  of  the  campaign  ;  Ingenuity  devises 
the  tactics  of  the  battle  ;  Caution  directs  the  opera- 
tions of  the  units  ;  Perception  is  the  Tommy  who 
makes  the  firing  line  and  comes  into  contact  with  the 
enemy. 

Objective  Thought  may  be  disordered  on  any  of  its 
levels,  but  before  examining  actual  disorder,  I  may  draw 
attention  to  the  disproportion  that  frequently  exists 
between  the  highest  and  the  second  level.  It  is  a 
frequent  occurrence  to  find  ingenuity  developed  out  of 
proportion  to  wisdom,  and  vice  versa.  When  cleverness 
is  in  excess  with  respect  to  wisdom,  the  resulting  charac- 
ter is  that  of  the  clever  fool — the  man  who  is  full  of 
ingenious  devices  to  do  that  which  is  not  worth  doing. 
To  say  that  he  will  invent  a  machine  for  turning  fresh 
eggs  into  stale  ones  is  no  doubt  an  exaggeration,  but 
many  of  his  devices  are  not  much  more  useful.  He  will 
scheme  and  plot  to  save  sixpence — at  an  expense  of 
half  a  crown.  He  is  full  of  schemes  and  devices  which 
make  us  wonder  that  so  much  ability  is  incompetent  to 
recognise  the  uselessness  of  them  all,  or  at  least  how 
much  better  such  ability  would  pay  if  it  were  turned 


90  A  TEXT-BOOK  OF  INSANITY 

into  other  channels,  and  expended  in  attaining  other 
ends.  But  wisdom  being  deficient,  the  choice  of  ends  is 
injudicious,  for  it  is  the  function  of  wisdom  to  select  the 
main  ends  to  be  sought.  It  sometimes  happens  that 
wisdom  is  conspicuously  deficient  while  ingenuity  is 
highly  developed,  and  the  consequence  of  this  combina- 
tion is  the  "  sane  lunatic,"  who  is  such  a  puzzle  and  such 
a  trial  to  those  who  have  charge  of  him.  His  conduct  is 
such  that  it  is  difficult,  and  may  be  impossible  to  lay 
one's  finger  on  any  act  or  speech  that  is  certainly  insane. 
We  caimot  say  of  any  one  thing  he  does  or  says  "  This 
is  insane  :  this  is  a  thing  that  no  sane  man  would  do  or 
say,"  and  yet,  when  viewed  by  and  large,  the  whole 
trend  of  his  conduct  leaves  no  doubt  upon  our  mind  that 
he  is  insane,  and  enables  us,  with  more  or  less  difficulty, 
even  to  convince  a  court  of  law  that  he  is  insane.  We 
are  all  familiar  with  such  cases,  and  it  is  extremely 
difficult  to  formulate  in  words  what  the  peculiarity  in 
mind  or  conduct  is  that  justifies  us  in  finding  insanity, 
and  compels  us  to  find  insanity.  Such  persons  are  the 
despair  of  their  families,  and  are  insoluble  problems  to 
the  general  practitioner,  who  may  be  for  years  convinced 
that  they  are  insane,  and  yet  may  be  wholly  unable  to 
state  in  a  certificate  any  single  *'fact  indicating  insanity 
at  the  time  of  examination."  Yet  if  we  keep  in  mind  the 
different  levels  of  intellect,  and  especially  the  difference 
between  wisdom  and  cleverness,  we  shall  have  little 
difficulty  in  discovering  where  the  disorder  is,  and  not  a 
great  deal  in  putting  it  into  words. 

Such  a  patient  is  for  ever  plotting  and  planning  and 
scheming ;  and  his  plots  and  plans  and  schemes  are 
very  ingenious,  very  clever,  and  very  often  successful 
in  achieving  their  immediate  purpose  ;  but  when  they 
have  achieved  their  immediate  purpose,  the  success  is 


THE  CLEVER  LUNATIC  91 

worthless  to  the  actor.  It  does  not  advance  him  in  the 
least  towards  any  ultimate  goal :  on  the  contrary,  it 
retards  him  and  baffles  him  in  attaining  what  he  most 
desires.  He  is,  we  will  say,  a  lunatic  so  found  by 
inquisition,  and  the  main,  the  ultimate  purpose  of  his 
life  is  to  get  his  supersedeas.  He  is  for  ever  contriving 
dodges,  tricks,  and  devices  to  outwit  those  who  have 
charge  of  him,  and  he  is  often  successful  in  outwitting 
them.  He  gets  letters  that  he  has  no  business  to  post 
posted  on  the  sly.  He  tempts  and  bribes  the  attendants 
and  others  to  commit  faults,  and  then  rounds  upon  them, 
accuses  them,  and  may  succeed  in  getting  them  punished. 
He  obtains  goods  here,  credit  there,  and  money  in 
another  place  ;  in  spite  of  all  our  care  and  vigilance  he 
succeeds  in  a  score  of  subtle  devices  ;  but  put  all  these 
successes  together,  and  what  do  they  amount  to  ?  Do 
they  carry  him  a  hair's-breadth  nearer  his  ultimate 
object  of  proving  his  sanity  ?  Not  a  bit.  The  more  he 
succeeds  in  his  malicious  tricks  and  dodges,  and  the 
more  he  gives  himself  up  to  them,  the  more  you  recognise 
the  ingrained  insanity  of  a  really  able  man  squandering 
his  ability  on  such  unworthy  ob j  ects .  Many  of  the  things 
that  he  seeks  to  obtain  by  cunning  and  underhand 
devices  he  could  have  for  the  asking  if  he  chose  to  be 
straightforward,  but  the  defect  of  wisdom  prevents  him 
from  seeing  this;  and  owing  to  the  same  defect  he 
cannot  appreciate,  even  when  he  is  told,  that  by  thus 
acting  he  is  demonstrating,  not  his  fitness,  but  his 
unfitness  to  be  at  large.  It  was  just  such  a  succession  of 
impish  tricks  that  brought  him  to  the  asylum,  and  yet 
the  defect  in  his  wisdom  prevents  him  from  under- 
standing that  the  continuance  of  these  impish  tricks  is 
keeping  him  there.  He  cannot  understand  this  because 
the  highest  level  of  his  intellect  is  disordered  and 


92  A  TEXT-BOOK  OF  INSANITY 

inefficient.  He  can  act  with  abundance  of  cleverness 
because  tbe  second  level  of  intellect,  originally  highly 
developed,  retains  its  integrity :  he  is  incapable  of 
directing  his  ability  to  the  highest  service  of  his  own 
welfare  because  the  highest  level,  wisdom,  is  out  of  order 
and  incapable  of  utilising  the  cleverness  and  ingenuity 
that  are  at  its  service. 

On  the  other  hand,  there  are  plenty  of  dull  people, 
more  or  less  lacking  in  cleverness  or  ingenuity,  who  are 
nevertheless  successful  in  life,  and  prove  by  their  suc- 
cess the  possession  of  a  normal  quantum  of  Wisdom. 
Realising  the  limitation  of  their  own  cleverness,  they 
take  such  places  in  the  world  as  do  not  require  clever- 
ness to  fill  capably.  They  set  before  themselves  no  aim 
that  they  are  incapable  of  attaining,  and  therefore  do 
not  fail.  Deficient  as  they  are  in  ingenuity,  which  is 
the  capacity  of  meeting  new  circumstances  in  new 
ways,  they  are  careful  to  keep  to  old  ways,  and  never 
to  adopt  a  new  device  until  it  has  been  well  tried  and 
found  successful  by  others.  The  determination  of  the 
main  ends  in  life  is  the  function  of  Wisdom,  and  in 
wisdom  they  are  not  deficient ;  hence  their  lives,  while 
never  strikingly  or  brilliantly  successful,  are  never 
arrant  failures.  Of  such  characters  the  great  bulk  of 
the  population  in  every  country  is  composed. 

It  has  been  said  above  that  disorders  of  Objective 
Intellect  have  received  from  alienists  a  monopoly  of 
importance  to  which  they  are  not  entitled.  This  is  true, 
for,  as  is  now  being  explained,  mind  may  be  disordered 
in  many  ways  and  in  many  departments  without  dis- 
playing any  of  those  erroneous  beliefs  that  were  once 
supposed  to  be  necessary  to  render  a  person  insane. 
But  at  the  bottom  of  the  practice  of  alienists  there  was 
a  residuum  of  truth.    Mind  may  be  disordered  in  many 


DEFECT  OF  INGENUITY  93 

departments  without  disorder  of  intellect ;  insanity 
may  include  many  disorders  of  mind  that  are  not  dis- 
orders of  intellect ;  but  whatever  the  disorder  of  mind 
may  be,  it  does  not  amount  to  insanity  unless  the 
highest  level  of  intellect  is  defective,  so  that  the  disorder 
of  mind  is  not  recognised  and  known  to  be  disorder ; 
and  whenever  this  highest  level  of  intellect  is  disordered, 
then  the  disorder  is  insanity,  whether  or  no  other  levels 
and  other  faculties  of  mind  are  implicated  in  the  dis- 
order. The  consequences  of  this  doctrine  are  of  the 
highest  importance,  as  will  be  seen  as  we  go 
along. 

When  the  second  level,  the  level  of  ingenuity,  is  dis- 
ordered or  defective,  the  result  is  dullness,  stupidity,  and 
confusion  of  thought ;  but  these  defects  are  by  no  means 
necessarily  insane.  If  the  highest  level  remains  un- 
affected, the  subject  of  the  disorder  recognises  and 
admits  the  disorder,  and  adapts  himself  to  it  as  far  as  he 
can.  Eecognising  that  his  mind  is  unequal  to  the 
performance  of  his  daily  work,  he  rests  from  it.  He 
does  not  attempt  the  ordinary  tasks  that  are  now 
beyond  his  power,  and  he  consults  his  doctor  for  the 
malady  that  he  knows  is  attacking  him.  In  so  doing  he 
proves  the  sanity  of  his  mind,  disordered  though  it  is. 
As  long  as  the  highest  level  of  intellect  is  intact,  any 
disorder  that  occurs  on  the  inferior  levels  is  recognised 
as  disorder,  and  measures  are  taken  to  counteract  and 
correct  it.  Illusion  is  known  to  be  illusion ;  hallucination 
to  be  hallucination;  groundless  suspicion,  fear,  panic, 
depression,  are  known  to  be  groundless  ;  imperative  idea 
is  known  to  be  absurd.  All  these  are  then  sane  disorders 
of  mind,  and  such  sane  disorders  are  frequent  enough. 
Every  book  on  psychology  expatiates  at  length  on  sane 
illusions.     Sane  hallucinations,   that  are  known  and 


94  A  TEXT-BOOK  OF  INSANITY 

recognised  by  the  subjects  of  them  as  hallucinations, 
though  not  frequent,  are  well  known  to  occur  ;  and 
frights,  panics,  depression,  suspicion,  as  well  as  many 
other  states  of  mind  that  are  unjustified  by  circum- 
stances, and  are  known  and  recognised  by  the  subjects  of 
them  to  be  unjustified,  are  of  frequent  occurrence. 
Such  disorders  are  quite  sane.  There  is  no  trace  of 
insanity  in  them.  They  are  not  described  in  books, 
for  they  rarely  come  before  writers  on  insanity,  and  if 
they  did,  the  writers  on  insanity,  holding  as  they  all  do 
that  insanity  is  disorder  of  mind,  and  that  disorder  of 
mind  is  insanity,  would  of  course  regard  them  as 
insane  ;  and  if  they  come  before  neurologists,  as  they 
probably  do,  the  neurologist  gets  what  knowledge  of 
disorder  of  mind  he  has  from  the  alienist,  and  takes  the 
same  view. 


SUBJECTIVE  INTELLECT 

Subjective  Thought  is  a  department  of  mind  that  has 
not  hitherto  been  described  or  even  recognised.  It 
consists,  as  already  explained,  in  the  estimation  of  our 
own  qualities,  and  its  extreme  importance  to  conduct, 
and  therefore  to  the  estimation  of  insanity,  is  plain. 
Intention  or  determination  to  do  this  or  that  depends 
on  several  factors,  some  of  which — desire,  estimation  of 
circumstances,  etc. — ^have  already  been  examined  ;  but 
it  is  clear  that  no  course  of  conduct  will  be  determined 
on  that  is  not  believed  to  be  within  our  powers,  and  this 
belief  must  rest  upon  the  estimate  that  we  form  of  our 
powers.  We  may  desire  to  get  from  Dover  to  Calais, 
and  we  may  correctly  estimate  the  distance  to  be 
about  twenty  miles,  but  in  casting  about  for  means  to 
compass  the  journey  we  shall  not  take  into  practical 


SUBJECTIVE  INTELLECT  05 

consideration  the  project  of  jumping  across.  Why  not  ? 
Clearly  because  we  estimate  our  own  powers  of  jumping, 
and  have  a  settled  belief  that  twenty  miles  is  more  than 
we  could  manage.  If  the  gap  of  water  that  we  want  to 
traverse  is  not  twenty  miles,  but  twenty  feet,  the 
difficulty  for  most  of  us  is  still  insuperable  ;  but  still,  in 
this  case  it  is  not  so  utterly  and  outrageously  beyond  our 
powers  that  we  do  not  give  it  at  any  rate  a  momentary 
consideration.  If  it  is  but  ten  feet,  we  may  seriously 
consider  it,  and  if  only  five,  many  would  try  it  without 
hesitation,  and  many  would  succeed ;  but  in  any  case, 
whether  an  act  is  to  be  attempted  or  not  depends, 
among  other  things,  upon  our  own  estimate  of  our  own 
ability  to  accomplish  it;  and  therefore  this  field  of 
estimation  is  a  very  important  department  of  the 
province  of  thought.  It  is  the  more  important  to  the 
alienist  since  it  is  very  liable  to  disorder. 

The  four  levels  of  Subjective  Thought  are  determined 
by  the  grade  of  the  power,  capacity,  ability,  or  other 
quaHty  that  is  the  subject  of  the  estimate.  On  the 
lowest  level  are  the  estimates  of  mere  physical  capacity. 
Everyone  can  tell,  with  a  more  or  less  close  approxima- 
tion to  accuracy,  what  his  physical  powers  are — 
whether  the  ditch  is  or  is  not  too  wide  to  leap  ;  whether 
the  stile  is  or  is  not  too  high  to  jump ;  whether  he  can 
reach  up  to  this  object,  or  Lift  that  one  ;  what  distance 
he  can  walk,  and  in  what  time ;  how  far  he  can  throw 
this  ball  or  that  stone ;  his  powers  of  endurance,  his 
manual  dexterity,  and  so  forth.  Such  estimates  are 
perpetually  being  made,  and  conduct  is  perpetually 
being  regulated  in  accordance  with  them.  Another 
branch  of  the  estimates  of  this  character  are  those 
concerning  the  magnitude,  weight,  and  other  statical 
attributes  of  our  own  bodies,  and  of  parts  of  them. 


96  A  TEXT-BOOK  OF  INSANITY 

Lying,  as  they  do,  at  the  base  of  subjective  estimation, 
estimates  of  this  level  are  disordered  late  in  disorder  of 
mind,  and  show  that  the  disorder  is  profound.  They  are 
therefore  not  nearly  so  frequent  as  disorders  on  the 
higher  levels,  but  still  we  sometimes  witness  them.  We 
see  patients  with  the  most  exaggerated  estimates  of 
their  own  powers,  and  of  the  magnitude  of  their  own 
bodies  or  limbs.  This  one  can  jump  over  a  house,  that 
can  lift  a  ship  out  of  the  water  by  his  own  unaided 
strength.  The  feat  of  jumping  across  the  straits  of 
Dover  appears  to  another  well  within  his  powers.  One 
patient  of  an  amorous  disposition  assured  me  that  his 
penis  was  fifteen  miles  long,  and  his  testes  as  big  as 
castles. 

The  next  level  is  constituted  naturally  by  estimates  of 
mental  capacity,  and  the  estimates  that  we  form  of  our 
own  ability  are  of  two  kinds — ^relative  and  absolute. 
Everyone  in  his  progress  through  life,  and  his  constant 
intercourse  with  his  fellows,  measures  himself  more  or 
less  deliberately  against  them,  and  estimates  his  own 
intellectual  capacity  relatively  to  theirs,  gets  to  know 
whether  he  is  above  or  below  the  average,  not  only 
generally,  not  only  with  respect  to  his  wisdom,  cleverness, 
or  caution,  but  also  with  respect  to  special  accom- 
plishments. He  learns  to  rank  himself  as  indifferent, 
fair,  good,  or  excellent,  as  a  linguist,  as  a  bargainer,  as 
a  musician,  an  organiser,  a  judge  of  character,  a  chess- 
player, or  what  not.  Besides  this  relative  estimate,  he 
learns  to  form  also  an  absolute  estimate  of  his  intellec- 
tual powers.  He  knows  what  he  can  understand  at 
once,  what  he  can  by  application  learn  to  understand, 
and  what  is  wholly  beyond  his  comprehension.  He 
learns  what  mental  capacities  he  possesses,  what  occupa- 
tion is  suitable  and  what  unsuitable  for  him,   what 


DEFECT   OF  WISDOM—INSANITY         97 

problems  lie  can  solve  unassisted,  and  for  what  he  must 
ask  for  assistance,  and  so  on. 

These  estimates  are  liable  to  err,  and  the  error  may- 
be within  or  without  the  limits  of  sanity.  Some  people 
are  so  happily  constituted  that  they  habitually  overrate 
their  own  capabihties  ;  and  although  this  leads  them 
to  undertake  tasks  for  which  they  are  incompetent  and 
in  which  they  fail,  the  failure  has  not  the  same  efiect  in 
producing  depression  and  despondency  that  it  has  on 
other  people.  Others,  unduly  modest,  underrate  their 
own  capabilities,  and  shrink  from  tasks  that  they  are 
well  able  to  perform.  In  such  cases,  however,  the  defect 
is  often  not  so  much  a  mistaken  underestimate  of  their 
own  intellectual  powers  as  a  lack  of  courage,  a  shrinking 
from  responsibihty,  an  unwilHngness  to  incur  the  risk  of 
failure  ;  and  the  fear  of  failure  is  often  itself  a  source  of 
failure. 

In  all  this,  however,  there  is  no  insanity.  Insanity 
does  not  exist  unless  the  estimate  of  mental  capacity  is 
grossly  and  exorbitantly  excessive  or  defective ;  and 
gross  and  exorbitant  error  in  either  direction  is  frequently 
witnessed.  One  person  will  cover  reams  of  paper  with 
wretched  doggerel,  and  boast  of  it  as  glorious  poetry ; 
another  will  be  certain  of  selHng  for  enormous  sums 
mere  unintelligible  scribbling  ;  others,  again,  will  lay 
claim  to  supernatural  acuteness  and  ability  in  the  most 
various  directions — acuteness  and  ability  of  which 
there  is  no  evidence  beyond  their  own  claim.  They  can 
square  the  circle,  and  demonstrate  the  flatness  of  the 
earth ;  they  can  read  the  thoughts  of  persons  a 
thousand  miles  away  ;  they  know  what  song  the  Sirens 
sang,  and  will  sing  it  to  you  in  a  voice  that  they  declare 
is  comparable  only  to  a  seraph,  but  that  seems  to  the 
hearer  a  discordant  noise  ;    they  can  penetrate  the 


98  A  TEXT-BOOK  OF  INSANITY 

secrets  of  all  the  Chancelleries  of  Europe,  and  tell  exactly 
how  each  of  them  ought  to  act ;  there  is,  in  short,  no 
limit  to  their  capacity. 

On  the  other  hand,  there  are  unfortunates  whose 
underestimate  of  their  own  powers  is  certainly  great, 
but  cannot  be  proved,  and  for  the  moment  may  even  be 
not  very  inaccurate.  They  stand  appalled  and  helpless 
before  problems  and  difficulties  that  in  health  they 
could  meet  and  solve  easily  enough,  but  that  now  are 
beyond  their  capacity  ;  so  far  their  own  estimate  of  their 
own  powers  is  not  perhaps  inaccurate,  but  they  extend 
this  inability  into  the  future  and  the  past,  and  declare 
that  they  have  always  muddled  everything  they  ever 
undertook,  and  will  never  be  competent  to  transact  the 
simplest  business.  In  this  the  limits  of  sanity  are 
passed. 

The  upper  middle  level  of  Subjective  Thought  is 
composed  of  estimates,  not  of  physical  or  mental 
capacity,  but  of  powers  more  extended — of  the  powers 
arising  from  the  possession  of  wealth,  influence,  and 
honour.  Of  course,  these  are  not,  strictly  speaking, 
altogether  subjective  estimates,  or  estimates  of  subjec- 
tive powers.  They  involve  and  require  as  antecedent 
conditions  certain  estimates  of  external  circumstances. 
They  are,  however,  so  closely  bound  up  with  the  purely 
subjective  estimates ;  they  so  surely,  or  at  least  so  com- 
monly, suffer  disorder  when  the  purely  subjective 
estimates  are  disordered,  the  disorder  is  so  invariably 
in  the  same  direction,  and  the  recovery  from  the  one  so 
regularly  accompanies  recovery  from  the  others,  that  it 
would  do  violence  to  evident  natural  affinities  to  place 
them  anywhere  but  in  association  with  these  others. 
The  estimates  of  this  class  are  estimates  of  possession  : 
they  refer  to  wealth,  power,  influence,  honour,  titles, 


DISORDER  OF  SELF-ESTIMATION        99 

possessed  by,  or  due  to,  the  estimator.  Normally  there  is 
little  room  for  error  in  estimates  of  this  class.  A  man 
of  great  wealth  may  not  know  the  whole  of  his  posses- 
sions, but  he  knows  that  he  is  a  very  wealthy  man.  A 
poor  man  whose  afiairs  are  very  complicated  may  not 
know  whether  he  is  actually  solvent  or  insolvent,  but 
he  knows  quite  well  that  he  is  near  the  border  line.  A 
man  can  scarcely  make  a  normal  mistake  as  to  his 
position  in  the  world,  or  the  title  by  which  he  has  a  right 
to  be  addressed  ;  and  though  he  may  not  have  a  very 
accurate  estimate  of  the  esteem  in  which  he  is  held  by 
his  neighbours,  he  knows  pretty  well  if  they  are  pre- 
pared to  acclaim  or  to  execrate  him  when  he  appears 
in  the  street. 

When  this  faculty  is  disordered,  these  estimates  are 
erroneous,  and  are  often  grossly  erroneous.  The  poor 
man,  or  the  man  of  moderate  means,  believes  that  he  is 
possessed  of  wealth  beyond  the  dreams  of  avarice  ;  the 
humble  dweller  in  a  back  street  fancies  that  he  can 
determine  the  fate  of  cabinets,  and  influence  the  destinies 
of  nations  ;  the  city  clerk  or  the  bricklayer's  labourer 
arrogates  to  himself  the  highest  titles  in  the  peerage, 
monarchy,  popedom,  godhead  itself.  The  ordinary  titles 
are  not  enough  to  satisfy  his  overweening  and  grotesque 
self-estimation,  and  he  invents  new  ones  of  which  no 
one  has  heard  the  like.  In  the  opposite  direction  of 
self -depreciation  the  exaggeration  is  never  so  enormous. 
He  who  is  near  the  ground  has  not  far  to  fall,  though  the 
boundless  expanse  of  heaven  is  above  him  to  soar  into. 
The  man  of  substantial  means,  or  even  of  great  wealth, 
often  beheves  that  he  is  ruined,  but  never,  in  my  ex- 
perience, that  he  is  groaning  beneath  a  load  of  inex- 
tinguishable debt.  He  looks  upon  himself  as  despised 
and  rejected  of  men,  as  insignificant,  of  no  account,  as 


100  A  TEXT-BOOK  OF  INSANITY 

neither  possessing  nor  deserving  of  influence  or  power, 
but  lie  does  not  often  invent  for  himself  titles  of  ignominy 
and  disgrace.  One  patient,  however,  stigmatised  himself 
as  the  Awful  of  Awfuls. 

Lastly,  the  highest  level  of  self-estimation  is  consti- 
tuted by  estimates  of  our  own  moral  worth.  This  is  a 
matter  that  in  the  normal  does  not  much  occupy  our 
thoughts  unless  we  have  unhappily  some  fault  to  regret ; 
and  when  the  faculty  is  disordered,  the  disorder  is 
seldom  in  the  direction  of  exaggerating  our  own  moral 
excellence,  or  if  it  is,  the  exaggeration  of  this  quality  is 
swamped  and  concealed  beneath  the  exaggeration  of  the 
estimates  on  the  second  level — of  wealth,  power,  and 
honour.  Self-depreciation  with  respect  to  the  moral 
quahties  is,  however,  a  frequent  symptom  of  disorder, 
and  may  take  the  form  of  self-accusations  either  of  crime 
or  of  sin.  False  but  conscientious  self -accusations  of 
crime  are  frequent  enough,  both  in  the  transient  insanity 
of  drunkenness,  and  in  cases  of  more  enduring  alienation  ; 
and,  without  any  definite  self-accusation  of  a  specific 
crime,  a  general  feeling  of  moral  delinquency,  and  a  belief 
in  a  past  of  criminal  actions  that  can  no  longer  be 
individually  remembered,  is  not  very  infrequent.  More 
frequent  still  are  ungrounded  self-accusations  of  sin, 
often  culminating  in  confession  of  the  unpardonable  sin, 
an  expression  that,  for  the  sake  of  these  unfortunates, 
one  could  wish  to  see  expunged  from  the  authorised 
version.  "What  men  mean  by  the  expression  is  usually 
the  practice  of  masturbation,  to  which  the  laity  attach 
such  exaggerated  importance,  taught  so  to  do,  no 
doubt,  by  the  medical  profession,  which  held  the  same 
view  until  I  ventured  to  question  it  five-and-twenty 
years  ago.  When  women  confess  to  the  same  inexpiable 
offence,  its  nature  is  not  usually  to  be  ascertained.    It 


EXALTATION  101 

is  certainly  not,  as  one  miglit  perhaps  have  expected, 
inchastity,  but  is  usually  a  vague  conviction  of  moral 
turpitude  of  no  specific  character.  Sometimes,  however, 
it  is  a  specific  act.  One  poor  girl,  described  to  me  how, 
when  her  lover  jilted  her,  she  lay  upon  her  bed  and 
cursed  the  Almighty,  who  had  suffered  him  to  do  so  ; 
and  this  was,  to  her  conscience,  the  unpardonable 
sin. 

The  exaggerated  estimate  of  our  own  powers  and 
worthiness,  upon  whatever  level  the  estimate  is  made, 
may  fitly  be  called  Exaltation,  and  should  be  dis- 
tinguished from  Exhilaration,  or  unjustified  joyousness 
or  gaiety,  with  which  it  is  always  confused  by  alienists. 
Similarly,  Abasement,  which  is  the  morbid  under- 
estimate of  our  own  powers  and  worthiness,  is  confused 
with  Depression,  which  is  lowness  of  spirits  or  misery.  The 
two  are  manifestly  different.  One  is  a  state  of  feeling, 
the  other  is  a  belief,  the  result  of  a  judgment  or  estimate. 
The  behef  that  constitutes  abasement  may  be  a  logical 
ground  for  depression,  but  it  is  not  the  same  as  depres- 
sion, though  it  often  accompanies  depression.  The  very 
fact  that  depression  occurs  apart  from  abasement  is 
enough  to  show  that  the  two  things  are  not  the  same. 
I  do  not  know  that  abasement  occurs  apart  from 
depression,  but  exaltation  occurs  often  enough  without 
any  exhilaration,  and  exhilaration  apart  from  ex- 
altation. The  exalted  person  is  rarely  depressed,  but  he 
may  be  depressed,  and  I  have  witnessed  the  combina- 
tion, though  it  is  certainly  unusual ;  but  he  is  very  often 
little  or  not  at  all  exhilarated  by  his  exaltation  ;  and 
the  queen  may  be  found  at  the  wash-tub  and  the  emperor 
carrying  coal,  neither  exhilarated  by  their  exalted 
rank,  nor  impressed  by  its  incongruity  with  their 
present  occupation. 


102  A  TEXT-BOOK  OF  INSANITY 

The  structure  of  Intellect  on  the  plan  here  proposed 
will  be  as  follows : — 


THOUGHT    OR   INTELLECT 
Objective  Thought  Subjective  Thought  (Self-Estimation) 

Wisdom.  Moral. 

Ingenuity.  Possessive. 

Caution.  Mental. 

Perception.  Physical. 

MEMORY 

The  last  constituent  of  mind  that  needs  consideration 
at  the  hands  of  the  alienist  is  Memory,  and  as  already 
said,  memory  differs  from  the  other  constituents  of  mind 
in  as  much  as  it  is  not,  as  they  are,  susceptible  of 
division  into  grades  or  levels.  It  has,  however,  different 
aspects,  which  the  alienist  must  bear  in  mind. 

That  memory  varies  much  in  different  persons,  so  that 
some  have  a  good  memory  and  others  a  bad  memory,  is 
sufficiently  notorious  ;  but  what  is  insufficiently  ap- 
preciated is  that  memory  differs  much  in  the  same  person 
for  different  things,  so  that  the  same  person  remembers 
some  things  well  and  other  things  badly  ;  and  the 
person  who  is  noted  for  the  wonderful  retentiveness  and 
accuracy  of  his  "  memory,"  meaning  thereby  what  is 
usually  meant,  viz.  his  verbal  memory,  may  have  an 
exceptionally  bad  memory  for  other  things  that  cannot 
be,  or  do  not  happen  to  be,  expressed  in  words  ;  and  may 
in  this  respect  be  vastly  inferior  to  the  person  with 
a  reputed  "  bad  memory."  For  instance,  two  men 
who  are  commonly  singled  out  as  the  possessors  of 
extraordinarily  good  m^emories — Dr.  Johnson  and  Lord 
Macaulay — ^had,   indeed,   wonderful   verbal  memories, 


MEMORY  103 

so  that  they  could  repeat  accurately  whole  pages  of 
books  that  they  had  recently  read  but  once,  and  quote 
accurately  passages  that  they  had  read  but  once  and 
that  years  ago ;  but  they  both  had  exceptionally  bad 
memories  for  musical  sounds  and  melodies.  Of  Macaulay 
it  is  reported  that  he  once  recognised  ''  God  Save  the 
Queen,"  but  no  similar  instance  is  recorded  of  Dr. 
Johnson,  and  it  is  unlikely  that  if  such  a  starthng  event 
had  occurred,  it  would  have  remained  unrecorded. 

It  is  not  necessary  to  discuss  here  the  various  factors 
that  help  or  interfere  with  the  tenacity  of  memories  ; 
they  are  fully  described  in  my  book  on  Psychology, 
and  elsewhere.  It  is,  however,  necessary  to  insist  here 
that  it  is  as  normal  to  forget  as  to  remember,  and  that 
it  may  be  as  abnormal  to  remember  as  to  forget.  It 
depends  upon  what  is  remembered  and  what  is  forgotten. 
To  have  enduring  memories  of  all  the  details  of  the 
domestic  day,  every  petty  act  and  movement,  every 
sound  that  is  heard,  every  thing  that  passes  under  the 
eyes,  every  trivial  word  that  is  interchanged,  would  be 
intolerable.  All  these  things  are  remembered  momen- 
tarily, can  be  recalled  after  a  short  interval,  but  are 
obliterated  by  the  first  sleep,  and  thereafter  are  remem- 
bered no  more.  On  the  other  hand,  there  are  certain 
things  that,  either  for  their  importance  in  our  lives,  or 
from  perpetual  repetition,  are  never  forgotten  unless  the 
memory  is  obliterated  by  disease.  No  one  normally 
forgets  the  way  about  the  house  or  the  neighbourhood 
in  which  he  has  lived  for  any  length  of  time,  unless, 
indeed,  he  is  bedridden.  No  one  normally  forgets  the 
name  of  wife,  husband,  or  child,  the  nature  of  his 
business,  or  the  matters  of  daily  routine  ;  and  of  single 
events,  no  one  forgets  the  church  in  which  he  or  she 
was  married,  no  woman  forgets  the  style  and  material 


104  A  TEXT-BOOK  OF  INSANITY 

of  her  wedding-dress,  tlie  place  in  which  she  spent  her 
honeymoon,  the  time  and  place  at  which  her  first  child 
was  born ;  no  man  forgets  the  nature  of  his  first  paid 
employment,  the  place  to  which  he  went  on  first  leaving 
the  parental  roof,  and  so  forth.  These  things,  and  such 
things  as  these,  are  indelibly  impressed  upon  the  mind, 
and  not  to  remember  them  is  clear  evidence  of  morbid 
forgetfulness. 

Morbid  defect  of  memory  is  of  three  main  kinds,  which 
are  quite  distinct,  occur  in  different  people,  and  are 
different  morbid  conditions. 

The  first  defect  is  that  in  which  those  things  are 
forgotten  which  are  enumerated  above,  and  which  it  has 
been  said  that  no  one  normally  forgets.  From  time  to 
time  persons  are  found  wandering  in  the  streets  and 
unable  to  give  any  account  of  themselves,  to  say  who 
they  are,  or  where  they  live,  or  to  give  any  information 
about  their  past  lives.  They  have  forgotten  not  only 
the  names  of  their  nearest  and  dearest,  but  even  their 
own  names,  and  the  whole  of  their  past  lives  seems  to 
be  completely  obliterated  from  their  memories.  Such 
people  are  not  always  found  wandering.  The  lapse  of 
memory  sometimes  takes  place  in  their  own  homes  ;  and 
curiously  enough,  they  may  recognise  the  famihar  faces 
and  figures  of  those  about  them,  though  they  are  unable 
to  remember  their  names.  Sometimes,  however,  they 
are  unable  to  remember  whether  the  husband  or  wife  is 
the  husband  or  wife.  Some  such  cases  are  allied  to,  if 
they  are  not  indeed  identical  with,  post-epileptic  auto- 
matism on  the  one  hand,  and  alternating  personality 
on  the  other,  two  conditions  that  in  my  opinion  are 
variants  of  one  another. 

The  second  defect  of  memory  is  an  exaggeration  of  the 
senile  defect.    In  this  condition  the  events  and  experi- 


DEFECTS   OF   MEMORY  105 

ences  of  the  moment  are  forgotten  as  soon  as  they  occur, 
while  the  events  of  the  remoter  past  are  remembered 
with  full,  and  it  may  be  with  much  exaggerated,  vividness 
and  detail.  In  extreme  cases  of  this  kind,  an  experience 
is  instantly  forgotten  the  moment  it  has  occurred. 
The  patient  has  no  sooner  written  a  letter  and  laid  it  on 
one  side  than  he  starts  to  write  it  again,  oblivious  that  it 
has  been  written  already.  Has  daughter  has  no  sooner 
left  the  room  than  he  begins  to  whimper  and  complain 
that  she  never  comes  near  him — ^has  not  seen  him  for  a 
month.  His  dinner  is  no  sooner  cleared  away  than  he 
rings  to  know  why  it  is  so  late  ;  and  so  forth.  The  com- 
monest and  mildest  example  of  this  defect  is  seen  in  the 
practice  of  elderly  people  to  tell  the  same  story  again  and 
again  at  short  intervals  to  the  same  person,  oblivious  of 
having  told  it  before.  This,  with  a  difficulty  in  recalling 
proper  names,  is  the  first  mental  sign  of  oncoming 
seniHty.  Together  with  this  lapse  of  memory  for  the 
most  recent  afiairs  is  apt  to  go  an  undue  vividness  of  the 
memories  of  things  long  past.  The  incidents  of  youth  and 
childhood  pass  before  the  mind  with  a  vividness  and 
persistence  that  may  make  them  seem  more  real  than 
the  state  of  things  actually  existing.  The  old  man  passes 
into  a  veritable  second  childhood,  and  calls  his  grand- 
children by  the  names  of  school-fellows  with  whom  he 
has  not  associated  for  sixty  or  seventy  years,  mistakes 
his  daughter  for  his  first  love,  and  his  wife  for  his  mother, 
and  seems  to  live  in  a  world  that  has  long  passed  away. 

The  third  defect  of  memory  is  of  a  totally  difierent 
kind.  Having  stated  once  in  the  witness-box  that  the 
plaintifi  suffered  from  defect  of  memory,  I  was  asked 
in  cross-examination  whether  he  had  not  shown  in  his 
evidence  that  his  memory  of  the  events  he  described 
was  very  good  ;  and  I  admitted  that  he  had,  but  these, 


106  A  TEXT-BOOK  OF  INSANITY 

I  said,  were  past  events.  "  And  would  you  expect  him," 
said  counsel  with  something  of  a  sneer,  "  to  remember 
future  events  that  have  not  yet  happened  ? "  and  he 
was  considerably  taken  aback  when  I  answered,  *'  Pre- 
cisely. It  is  for  future  things  that  his  memory  is  so 
defective."  The  statement  is  paradoxical,  but  it  is 
quite  true.  Among  the  things  that  we  have  to  remember, 
and  that  it  is  most  important  for  us  to  remember,  are 
things  that  are  going  to  happen.  We  should  not  often 
catch  a  train  unless  we  remembered  at  what  time  it  is 
going  to  start.  How  often  do  we  not — some  of  us — 
find  our  visit  to  a  shop  fruitless  because  we  have  for- 
gotten the  hour  at  which  it  was  going  to  close  !  What 
is  more  important  to  a  business  man  than  to  remember 
the  appointments  that  he  has  to  keep  ?  The  whole 
efficiency  of  men  in  many  occupations  lies  in  remember- 
ing correctly  what  things  have  to  be  done  at  what  times. 
What  is  the  value  of  a  nurse  who  forgets  when  dressings 
are  to  be  changed,  when  food  is  to  be  given,  when 
remedies  are  to  be  administered,  when  the  doctor's 
visits  are  to  be  expected  ?  This  is  a  special  form  or 
mode  of  memory,  quite  different  from  the  memory  of 
what  one  has  read  or  heard  or  seen,  which  is  what  usually 
comes  into  the  mind  when  memory  is  spoken  of.  It  is 
the  form  of  memory  which  is  by  far  the  most  useful  in 
the  practical  affairs  of  life,  and  is  by  no  means  necessarily 
developed  in  proportion  or  in  association  with  the 
memory  of  what  has  been  read  in  books.  Rather  there 
seems  to  be  a  certain  antagonism  between  them,  so  that 
the  most  learned  man  is  the  man  least  likely  to  remember 
an  appointment,  and  the  practical  man,  who  never 
forgets  to  perform  in  due  order  any  of  his  multifarious 
duties,  is  the  man  least  able  to  acquire  knowledge  from 
books.     Defect  of  what  may  be  called  the  practical 


MNEMONIC  DELUSION  107 

memory  is  a  frequent  disorder  of  mind.  In  many  people 
it  seems  to  be  either  originally  defective,  or  to  be 
defective  from  want  of  cultivation,  and  in  these  people, 
who  are  called  absent-minded,  it  is  not  serious  ;  but 
when  it  becomes  defective  in  those  in  whom  it  has  been 
cultivated  to  a  high  pitch,  the  defect  is  a  serious  one,  not 
only  on  account  of  its  practical  inconvenience,  but 
because  it  may  mean  grave  disease.  It  is  among  the 
earliest  signs  of  one  form  of  general  paralysis.  It  is 
sometimes  the  consequence  of  injury  to  the  head.  And 
it  is  usually  accompanied  by  confusion  of  thought. 

The  last  disorder  of  memory,  and  the  last  disorder  of 
mind  with  which  the  alienist  need  concern  himself,  is 
not  a  defect.  It  is  rather  an  excess.  It  consists  in  what 
I  have  called  mnemonic  delusion  ;  that  is  to  say,  an 
event  which  never  occurred  at  all  is  remembered,  or 
appears  to  be  remembered.  It  is  imagined  and  pro- 
jected, or  retrojected,  back  into  the  past,  and  is  to  the 
subject  of  it  a  memory.  Such  false  memories,  or  mne- 
monic delusions,  occur  chiefly  in  chronic  alcoholism  ; 
and  the  vividness,  detail,  and  particularity  of  the 
memory  are  often  remarkable.  A  single  instance  will 
suffice.  I  was  driving  one  day  with  an  old  gentleman, 
the  subject  of  alcohohc  insanity,  when  all  at  once  he 
tried  to  get  out  of  the  carriage  while  it  was  going  rapidly. 
I  forcibly  prevented  him  from  getting  out,  and  in  the 
struggle  one  of  his  fingers  was  dislocated.  The  disloca- 
tion was  reduced  and  the  finger  put  up  in  a  splint,  and  a 
few  hours  afterwards,  when  he  was  asked  how  the 
accident  happened,  he  gave  the  following  account  of  it : 
"  I  was  going  upstairs,"  he  said,  "  and  one  of  the  stair- 
rods  had  been  taken  out,  leaving  the  stair-carpet  in  a 
loose  fold.  It  slipped  under  my  feet,  and  I  fell  forward, 
catching  the  tip  of  my  finger  against  the  edge  of  the 


108 


A  TEXT-BOOK  OF  INSANITY 


stair  above.  The  finger  was  bent  quite  back,  and  put 
out  of  joint."  To  this  account  he  adhered  for  a  time; 
but  it  was  subsequently  changed  for  another,  equally 
imaginary,  and  related  in  equally  good  faith.  Fortun- 
ately the  delusion  was  innocuous,  and  implicated  no  one 
in  any  fault ;  but  it  is  manifest  that  the  imaginary 
memory  might  have  been  of  an  unjustifiable  assault ;  and 
in  any  case  my  old  friend  would  have  been  quite  prepared 
to  go  into  the  witness-box  and  swear  with  a  clear 
conscience  that  his  account  was  the  true  one.  Such 
delusions  are  therefore  not  free  from  danger  to  others. 


SUMMARY 

The  total  constitution  of  Mind,  as  far  as  the  alienist 
needs  to  take  it  into  his  consideration,  that  is  to  say, 
the  regions  of  mind  that  are  subject  to  such  flagrant 
disorder  as  to  enter  into  insanity,  or  otherwise  to  call  for 
the  services  of  the  physician,  may  be  tabulated  in  the 
following  manner  : — 


Desire. 

Will. 

Main  Ends 
Subordinate 
Sub-subordinate 
Trivial 

Feeling. 

Thought. 

Memory. 

Subjective 

Objective 

Subjective 

Objective 

Social 
Selfish  II 
Selfish  I 
Racial 

Moral 
Esthetic 
Euphoric 
Crude 

Social 
Esthetic 
Emotion 
Sensation 

Moral 
Possessive 
Mental 
Physical 

Wisdom 
Ingenuity 
Caution 
Perception 

This  Table  is  complicated  and  elaborate,  no  doubt, 
but  it  is  less  complicated  and  elaborate  than  the  constitu- 
tion of  Mind.    There  is  no  faculty,  and  no  level  of  any 


CONSTITUTION  OF  MIND 


109 


faculty,  that  is  enumerated  in  the  Table  that  is  not 
subject  to  disorder  of  such  consequence  as  to  call  for  the 
investigation  of  the  physician  ;  and  the  physician  for 
mental  diseases  who  has  not  them  all  at  his  fingers' 
ends,  and  cannot  immediately  relegate  a  disorder  to  its 
proper  compartment,  is  not  equipped  for  his  profession, 
and,  to  put  it  bluntly,  does  not  know  his  business.  It 
would  be  easy  to  simpHfy  the  Table  by  omitting  some 
faculties,  but  then  it  would  not  serve  its  purpose.  As 
it  is,  it  does  not  pretend  to  be  an  exhaustive  account 
of  the  constitution  of  mind ;  it  is  merely  a  convenient 
plan  of  so  much  of  mind  as  is  found  in  the  consulting 
room  to  be  subject  to  disorder. 

Blank  forms  of  this  diagram  should  be  inserted  in  the 
case  book  of  the  physician  for  mental  diseases,  and  the 
faculty  and  level  that  are  disordered  in  any  case  can  be 
indicated  by  shading.  A  few  specimen  diagrams  of 
various  forms  of  disease  are  here  inserted  as  models. 


Anoia  in  deep  dementia. — All  the  highest  and  upper 
middle  levels  are  lost.  Memory  also  is  for  the  most  part 
absent.  The  lowest  level  remains — sexual  and  crude  self- 
preservative  desires,  simple  efiorts  of  will,  feelings  of 
effort  are  left-,  but  some  sensations  are  diminished.    The 


110 


A  TEXT-BOOK  OF  INSANITY 


lowest  level  of  subjective  thought  is  damaged,  so  that 
the  patient  does  not  know  of  what  exertion  he  is 
capable.  Perception  remains,  but  the  estimation  of  the 
harmful  action  of  things  perceived  is  diminished. 


II 


Destre 

Will 

FeeUitg 

TK-ou/^Mi 

Menwn/ 

6uXj. 

Olj. 

3ixhj. 

Olj. 

g//m 

im 

Exalted  delusion  without  elation. — Delusion  shows 
disorder  of  thought.  Exaggeration  of  his  own  pos- 
sessions, titles,  etc.,  shows  disorder  on  the  upper  middle 
level  of  subjective  thought.  Inability  to  correct  shows 
defect  of  the  highest  level  of  both  subjective  and 
objective  thought. 

Ill 


DeiL}*e 

Will 

Fe  eltn^ 

Tlioatjk/fc 

Mem/Oftj 

Sitbj. 

oy. 

3uJ^. 

oy. 

'4'il!''. 

Sane  hallucination. — The  only   disorder  is  of  per- 
ception.   As  the  patient  is  able  to  correct  his  perception, 


CONSTITUTION  OF  MIND 


111 


and  knows  that  it  is  erroneous,  the  highest  level  of 
thought  is  unaffected,  and  there  is  no  insanity. 


IV 

DesiKe 

Will 

Feeling 

Tkou/Cjlit 

Wiciiiori) 

Siilj- 

oy. 

5al;j. 

OOj. 

'f& 

fk 

m 

f 

'''9/A 

■''% 

Paranoia  with  grandiose  delusion  and  hallucination. 
Shading  of  the  lowest  level  of  objective  thought  indicates 
the  disorder  of  perception.  The  lower  middle  level  of 
the  same  faculty — estimation  of  the  harmful  quality  of 
circumstances — also  is  disordered.  The  patient  over- 
estimates his  own  ability  and  his  rank,  shown  by  shading 
of  the  two  middle  levels  of  subjective  thought.  The 
inability  to  correct  these  errors  indicates  defect  of  the 
highest  level  of  both  sides  of  thought.  Cleverness  is  but 
slightly  diminished. 


Acute    insanity    of   melancholic    type   with    suicidal 


112 


A  TEXT-BOOK  OF  INSANITY 


desire  {lower  middle  level  of  desire). — Dysphoria  is 
shown  by  shading  of  the  lower  middle  level  of  subjective 
feeling.  The  disorder  spreads  to  the  highest  level  as 
shown  by  feeling  of  wickedness.  Uncalled-for  fear 
shows  disorder  of  emotion  (lower  middle  level  of  objec- 
tive feeling)  and  spreads  up  to  the  highest  level  of  this 
faculty,  where  it  exhibits  itself  as  remorse.  Both 
subjective  and  objective  thought  are  disordered  on  the 
upper  three  levels,  as  shown  on  the  subjective  side  by 
underestimation  of  moral  worth  and  mental  ability,  on 
the  objective  side  by  delusions  of  misfortune  in  circum- 
stances, by  diminished  intelligence  and  by  loss  of 
wisdom  and  of  the  power  of  estimating  self  and  circum- 
stances correctly. 


VI 


Desive 

Will 

Feelintj 

TfioagKt 

Mentori^ 

Su/ly. 

06j. 

.Su/Iaj. 

Obj. 

m. 

^- 

Agorophohia  or  Claustrophobia.  —  Malestimation  of 
the  power  of  perceived  circumstances  to  harm  (lower 
middle  of  objective  thought)  and  unjustified  fear  (lower 
middle  of  objective  feeling). 


PAET  II 

FORMS,   TYPES,   AND   KINDS   OF 
INSANITY 


CHAPTER  IV 

THE  CLASSIFICATION   OF  INSANITY 

The  classification  of  insanity  is  admitted  by  everyone 
to  be  unsatisfactory.  Every  writer  on  tbe  subject  has 
his  own  classification,  which  is  different  from  that  of 
every  other  writer.  Various  schemes  have  been  drawn  up 
by  committees  and  official  bodies,  but,  I  say  it  after 
examining  a  very  large  number  of  classifications,  the 
results  both  of  individual  and  of  collective  effort,  there 
is  not  one  that  does  not  violate  the  fundamental  rules 
of  classification. 

In  the  year  1905  a  strong  Committee  of  the  Medico- 
Psychological  Association  drew  up  a  classification  which 
has  since  been  adopted  by  the  Lunacy  Commission,  and 
owing  to  this  official  approval  has  superseded,  in  this 
country  at  least,  all  previous  classifications.  To  that 
Committee  I  was  Secretary,  and  I  am  therefore  without 
antagonistic  bias  when  I  say  that,  having  taken  into 
consideration  all  previous  classifications,  it  produced  a 
scheme  which  is  almost  as  faulty  as  any  of  its  pre- 
decessors— a  scheme  which  violates  every  canon  of 
classification ;  which  does  not  define  or  delimit  the  group 
of  things  to  be  classified  ;  which  fails  to  find  a  place  for 
some  of  these  things  ;  and  which  admits  things  that  are 
outside  the  boundary  of  insanity.  The  several  classes 
of  equal  rank  are  founded  upon  different  principles  of 
division,  and  therefore  the  scheme  allows  of  abundance 

115 


116  A  TEXT-BOOK  OF  INSANITY 

of  cross-classification.  These  objections  are  common  to 
this  and  to  every  other  scheme  of  classification  of 
insanity  that  has  ever  been  proposed,  and  it  is  suf- 
ficiently clear  that  no  classification  can  possibly  be 
satisfactory  to  which  any  one  of  these  objections  can  be 
justly  made.  It  is  clear  that  no  previous  classifier  has 
ever  been  at  the  trouble  to  acquaint  himself  with  the 
rules  or  canons  of  classification,  still  less  to  make  any 
attempt  to  abide  by  them.  It  may  be  well,  therefore,  to 
set  them  forth  here,  in  order  that  critics  may  judge 
whether  they  are  observed  or  not. 

The  first  step  towards  forming  a  valid  classification  is 
to  delimit  the  group  of  things  to  be  classified — to  draw 
a  line  round  them,  including  them  all,  and  excluding 
all  other  things.  The  second  requisite  is  that  each  step 
in  the  classification  must  be  made  according  to  the 
presence  or  absence  of  one  single  quality,  or  according  to 
the  modes  or  degrees  of  one  single  quality  and  no  more. 
If  these  conditions  are  observed,  the  classification  will 
include  all  the  things  that  ought  to  be  included  in  the 
classification,  and  nothing  that  ought  not ;  and  the 
classes  will  be  mutually  exclusive,  so  that  nothing  that 
is  in  any  one  class  can  possibly  be  placed  in  any  other 
also.  In  other  words,  the  classification  will  be  a  valid 
classification.  If  either  of  these  conditions  is  violated, 
the  classification  will  be  faulty  in  one  or  other  of  the 
respects  mentioned,  and  will  not  be  a  valid  classification. 
In  every  classification  of  insanity  hitherto  proposed  they 
have  both  been  violated. 

The  first  step  in  making  a  classification  is  to  settle 
what  it  is  that  we  have  to  classify — to  set  out  the  limits 
of  the  class  of  things  that  we  propose  to  subdivide,  so 
that  the  classification  may  include  them  all,  and  may 
exclude  everything  else.    In  other  words,  the  first  step 


THE  CLASSIFICATION  OF  INSANITY    117 

in  making  a  classification  is  to  define  the  group  of  things 
to  be  classified. 

The  things  to  be  classified  are  cases  or  instances  of 
insanity,  and  one  reason  for  the  utter  failure  of  every 
classification  of  insanity  hitherto  proposed  is  that 
insanity  has  never  been  satisfactorily  defined.  It  never 
could  be  satisfactorily  defined,  and  for  this  reason,  that 
the  name  insanity  has  always  stood  for  more  than  one 
concept.  We  have  been  and  are  in  the  habit  of  speaking 
of  insanity  as  if  by  this  name  we  meant  only  one  thing 
and  always  the  same  thing  ;  whereas,  in  fact,  the  name 
insanity  stands  for  more  than  one  thing — ^has  more 
than  one  meaning — and  when  we  use  the  name  we 
mean  sometimes  one  thing  and  sometimes  another. 
This  would  not  matter  in  the  least  if  we  knew  and 
recognised  that  the  name  has  more  than  one  meaning, 
and  if  we  always  kept  the  meanings  distinct  in  our 
minds.  No  confusion  arises  from  our  habit  of  calling  a 
beam  stuck  upright  in  the  ground  by  the  same  name  as 
is  used  to  denominate  a  delivery  of  letters  ;  but  to  a 
person  who  did  not  know  these  two  meanings  of  the 
word  *'  post "  the  use  of  it  alternately  in  the  two  senses 
would  be  puzzling.  No  confusion  need  result  from 
using  the  name  insanity  in  more  than  one  sense,  but 
confusion  does  result  because  the  meanings  are  not 
distinguished,  and  we  do  not  know  that  we  are  using 
the  word  in  more  than  one  sense. 

We  found  in  a  previous  chapter  that  insanity  is  a 
quadruple  disorder  of  (1)  Conduct,  (2)  Mind,  and  (3) 
Metabolism,  all  dependent  on  (4)  disorder  of  the  action 
of  the  highest  region  of  the  brain.  This  is  one  concept 
of  insanity,  but  it  is  not  the  only,  nor  even  the  usual 
concept.  I  do  not  think  that  anyone  but  myself  includes 
disorder  of  metabolism  in  the  concept  of  insanity,  though 


118  A  TEXT-BOOK  OF  INSANITY 

it  is  often  a  very  conspicuous  factor  in  the  concept  to 
me  ;  and  it  is  certain  that  we  can  think  and  often  do 
think  of  insanity  as  disorder  of  conduct  and  mind,  not 
only  without  connecting  these  disorders  with  disorder  of 
metabolism,  but  also  without  at  the  moment  taking  up 
into  the  concept  the  disorder  of  brain  process.  Here, 
therefore,  are  three  different  concepts  all  called  by  the 
name  insanity — the  fourfold  disorder  of  conduct,  mind, 
metabolism,  and  brain-process  ;  the  threefold  disorder  of 
conduct,  mind,  and  brain-process  ;  and  the  twofold 
disorder  of  conduct  and  mind.  There  are  alienists  who 
deny  that  disorder  of  conduct  forms  any  part  of  their 
concept  of  insanity,  but  those  who  make  this  denial  have 
peculiar  notions  of  conduct  and  of  disorder  of  conduct 
which  put  their  views  outside  the  pale  of  the  present 
discussion.  What  they  mean  by  conduct  I  do  not  know, 
except  that  they,  or  some  of  them,  consider  it  a  part  of 
mind.  It  is  clear  that  they  do  not  mean  by  it  what  I 
mean  by  it,  that  is  to  say,  the  way  a  person  acts  and 
talks,  for  if  they  did  mean  this,  they  could  not  fail  to 
admit  that  erroneous  ways  of  acting  and  talking  do 
enter  into  the  concept  of  insanity.  Others  evidently 
think  that  disorder  of  conduct  means  disorderly  conduct 
in  the  police  court  sense,  and  I  do  not  think  this  view 
merits  serious  refutation.  Everyone  who  understands 
ordinary  familiar  English  words  in  their  ordinary 
familiar  meanings  must  admit  that  it  is  impossible  to 
think  of  insanity  without  including  in  the  concept 
disorder  or  error  in  what  the  insane  person  says  and 
does. 

The  necessity  of  including  disorder  of  mind  in  the 
concept  is  a  little  more  doubtful.  Insanity  is  already 
complete  when  conduct  is  disordered,  and  in  many 
cases  no  more  need  be  considered  :   in  many  cases  no 


VARIOUS  CONCEPTS  OF  INSANITY      119 

more  is  considered,  for  a  time,  at  any  rate  ;  and  in 
those  cases  in  which  disorder  of  mind  does  enter  into 
the  concept,  the  nature  and  extent  of  the  disorder  is 
always  somewhat  conjectural,  and  is  often  largely  or 
entirely  conjectural.  It  is  quite  true  that  insanity  is 
always  called  disorder  of  mind,  and  is  never  called 
disorder  of  conduct,  but  this  is  merely  an  instance  of  the 
common  tyranny  of  the  word.  When  we  say  that  a 
person's  mind  is  disordered,  what  we  mean  is  that  he 
acts  or  talks  strangely  and  abnormally ;  and  if  he  did 
not  so  act  and  talk  we  should  never  know  and  never 
care  whether  his  mind  was  disordered  or  not.  Still,  apart 
from  the  mere  use  of  the  terms  mental  disorder  and 
disorder  of  mind,  which  are  used  as  equivalents  of 
insanity  without  any  necessary  reference  to  actual 
mental  states  or  processes  that  are  working  in  a  dis- 
orderly manner,  no  doubt  we  do  in  many  cases  of 
insanity  look  behind  the  disorder  of  acting  and  talking, 
and  infer  from  them  some  disorder  of  mind  ;  and  no 
doubt  we  always  ought  to  regard  the  disorder  in  acting 
and  talking  as  representative  and  significant  of  disorder 
of  mind,  and  so  bring  mental  disorder  into  our  concept 
of  insanity.  We  may  take  it,  therefore,  that  the  very 
minimum  concept  that  is  in  our  minds  when  we  speak 
or  think  of  insanity  is  the  twofold  disorder  of  conduct 
and  of  mind. 

Although  we  can,  and  often  do,  thus  conceive  insanity, 
we  do  not  often  allow  this  concept  to  remain  in  our 
minds  in  its  simplicity.  We  usually  bring  it  into 
relation  with  disorder  of  brain  function,  and  bring  it 
into  relation  in  one  of  two  ways.  In  the  first  way,  we 
keep  the  disorder  of  brain  function  separate  from  the 
disorders  of  conduct  and  mind,  and  regard  the  latter  as  a 
symptom  of  the  former.    In  the  second,  we  combine 


120  A  TEXT-BOOK  OF  INSANITY 

tlie  three  disorders  together  into  a  single  concept,  and 
regard  this  threefold  disorder  as  a  disease.  In  the  first 
case,  there  are  two  concepts,  the  disorder  of  conduct 
and  mind  on  the  one  hand,  and  the  disorder  of  brain 
function  on  the  other,  and  these  are  regarded  in  the 
relation  of  symptom  and  basis.  In  the  second  case  there 
is  but  one  concept,  of  disorder  of  conduct,  mind,  and 
brain,  amalgamated  into  a  disease. 

It  is  as  well  to  state  here  exactly  what  I  mean  by  a 
symptom  and  by  a  disease,  since  there  are  no  authorita- 
tive definitions  of  these  terms,  and  until  they  are  defined 
it  is  difficult  to  make  my  meaning  clear.  By  a 
symptom  I  mean  a  sign  or  manifestation  of  disorder  of 
some  function.  The  sign  may  be  perceptible  to  the 
patient  alone,  as  in  the  case  of  pain ;  or  it  may  be 
perceptible  to  the  bystander  alone,  as  in  the  case  of  coma ; 
or  it  may  be  perceptible  to  the  skilled  examination  of 
the  physician  alone,  as  in  the  case  of  a  cardiac  murmur 
or  a  water-hammer  pulse  ;  or  it  may  be  perceptible  to 
both  the  patient  and  the  bystander,  as  in  the  case  of 
tumour  or  rash  ;  but  in  any  case  a  symptom  is  a  sign 
or  manifestation,  perceptible  to  someone,  that  some 
function  is  gone  wrong.  Disorder  of  conduct  is  a  sign 
or  manifestation  that  the  higher  function  of  the  brain  is 
gone  wrong,  and  we  often  infer  so  directly  from  disorder 
of  conduct  and  from  altered  demeanour,  which  is,  of 
course,  a  part  of  conduct,  to  disorder  of  mind,  that  we 
seem  to  observe  the  disorder  of  mind ;  and  no  doubt 
uneducated  and  untrained  persons  think  they  do 
observe  the  disorder  of  mind.  So  that,  by  a  little 
straining  and  stretching  of  the  meaning  of  the  words, 
we  may  regard  the  disorder  of  mind  that  we  do  not 
observe,  but  infer,  as  a  symptom  of  disorder  of  brain- 
function,  just  as  we  regard  the  endocarditis  that  we  do 


THE  MEANING  OF  DISEASE  121 

not  observe,  but  infer, as  a  symptom  of  acute  rheumatism. 
The  expressions  are  not  strictly  correct,  but  they  are 
convenient  fictions. 

By  a  disease  I  mean  the  whole  group  of  correlated 
disorders  from  which  the  patient  suffers.  The  whole  of 
the  disorders  from  which  a  patient  suffers  need  not  be 
a  single  disease.  A  person  may  suffer  from  two  or  more 
diseases  at  the  same  time.  He  may  suffer  from  curva- 
ture of  the  spine  and  psoas  abscess,  and  since  these  are 
correlated  together  by  their  dependence  upon  a  single 
cause — tuberculosis  of  the  vertebrae — they  are  not 
different  diseases,  but  parts  of  a  single  disease.  But  he 
may  suffer  also  from  chilblains,  or  from  scarlet  fever, 
or  from  rickets,  and  since  these  cannot  be  correlated 
together  by  dependence  on  a  single  cause,  since  they  are 
not  different  manifestations  of  a  single  disorder,  they 
are  not  one  disease  but  several  diseases.  Cough,  dys- 
pnoea, hvidity,  dropsy,  and  a  cardiac  murmur  are  all 
symptoms  of  mitral  disease.  Taken  together  with  the 
distortion  of  the  mitral  valve,  and  with  any  other 
disorder  produced  by  this  distortion,  such  as  alteration 
of  the  pulse,  they  constitute  the  disease  from  which  the 
patient  suffers,  the  disease  being  the  whole  group  of 
correlated  disorders — the  whole  group  of  symptoms 
together  with  the  underlying  disorder  to  which  they  are 
all  due. 

In  the  light  of  this  definition,  is  insanity  a  disease  ? 
If  we  mean  by  insanity  disorder  of  conduct  and  mind 
only,  then  insanity  is  not  a  disease,  but  a  symptom  of 
disorder  of  brain.  But  if  we  mean  by  insanity 
disorder  of  conduct  and  mind  plus  disorder  of  brain,  is 
such  insanity  a  disease  ?  Clearly  it  is,  if  these  constitute 
the  whole  of  the  group  of  correlated  disorders  from 
which  the  patient  suffers.   Thus  in  many  cases  dysphoria 


122  A  TEXT-BOOK  OF  INSANITY 

with  its  expression  is  a  disease,  and  in  many  cases  excited 
conduct  is  a  disease.  But  there  are  also  many  cases  in 
which  the  disorder  of  conduct,  mind,  and  brain  do  not 
constitute  the  whole  of  the  group  of  correlated  disorders 
from  which  the  patient  suffers.  We  frequently  see  this 
group  correlated  with  specific  fevers — with  typhoid, 
scarlet  fever,  measles,  small-pox,  and  so  forth.  When 
so  correlated,  insanity  is  not  a  disease,  but  a  symptom 
of  the  wider  disease.  So  well  is  this  recognised  that  in 
such  circumstances  insanity  is  not  called  insanity.  It 
is  called  delirium,  and  regarded  as  a  symptom  of  the 
fever.  But  if  insanity  can  be  a  symptom  of  fever,  it 
can  be  a  symptom  of  other  diseases,  if  it  is  correlated 
with  those  diseases  and  due  to  the  same  underlying 
cause.  Now  insanity  as  a  symptom — disorder  of  con- 
duct and  mind — is  found  associated  with  some  other 
diseases,  such  as  myxoedema,  gout,  Graves'  disease, 
and  so  forth,  sufficiently  often  to  lead  us  to  suppose  that 
it  is  correlated  with  them,  so  that  whatever  poison  or 
other  agent  produces  the  other  symptoms  of  these 
diseases  produces  the  insanity  also.  In  such  cases  the 
insanity  is  not  a  disease,  for  it  does  not  constitute  the 
whole  of  the  correlated  group  of  disorders,  and  is  there- 
fore one  of  the  symptoms  only  of  the  disease.  It  would 
be  a  great  improvement  in  our  nomenclature  if  the 
symptom  insanity  were  always  called  delirium,  as  it  is 
when  it  is  a  symptom  of  specific  fever.  We  are  accus- 
tomed to  think  of  delirium  as  a  symptom,  just  as  we  are 
accustomed  to  think  of  insanity  as  a  disease  ;  and  if  the 
separate  names  were  allotted  severally  to  the  distinct 
things,  it  would  save  a  good  deal  of  confusion  of  thought. 
I  have  said  that  in  one  concept  of  insanity,  and  that 
which  I  regard  as  the  only  complete  concept,  the  dis- 
order is  fourfold,  and  includes  disorder  of  metabolism, 


SYMPTOM  AND  DISEASE  123 

disorder  which  shows  itself  sometimes  in  conspicuous 
alteration  in  the  integuments,  in  the  skin,  sweat,  hair 
and  nails,  and  in  chilblains  and  other  cutaneous  change. 
If  these  are  correlated  with  the  insanity,  if,  that  is  to  say, 
they  depend  on  the  same  disorder  of  the  brain  as  that 
to  which  the  insanity  is  due,  then  according  to  the 
doctrine  here  laid  down,  they  are  part  of  the  disease. 
The  whole  disease  may  still  be  called  insanity,  and  of 
this  disease  the  structural  change  in  the  integuments  is 
a  part  and  a  symptom.  If  the  symptom  insanity  occurs 
in  the  course  of  some  specific  fever,  then  the  insanity  is 
similarly  accompanied  by  a  structural  change  in  the 
skin — by  a  rash — but  we  do  not  now  call  the  whole 
disease  insanity  and  regard  the  rash  as  a  symptom  of 
the  insanity,  and  the  reason  is  plain.  The  disease  is  not 
insanity  because  the  disorder  of  conduct,  mind,  and  brain 
is  not  the  whole  disorder  from  which  the  patient  suffers  ; 
and  the  remaining  disorder  is  not  part  of  the  insanity, 
because  it  is  not  due  to  the  disorder  of  brain  function 
which  is  the  central  disorder  in  the  insanity  and  to 
which  the  other  disorders  of  the  insanity  are  due.  On 
the  contrary,  the  factor  which  correlates  the  whole  of 
the  disorders,  causes  them  all,  and  constitutes  them  one 
disease,  is  the  microbe  of  small-pox,  or  scarlet  fever,  or 
measles,  or  what  not. 

Now  apply  this  principle  to  the  case  of  general 
paralysis  of  the  insane.  Is  it  a  bodily  disease,  of  which 
insanity  is  a  symptom,  or  is  it  insanity  of  which  bodily 
disease  is  a  part  ?  Certainly,  the  symptom  insanity — 
the  disorder  of  mind  and  conduct — is  far  from  being  the 
whole  of  the  disease.  The  physical  symptoms  also  are 
conspicuous  and  important,  and  of  these  the  patient  at 
length  dies.  From  the  pupillary  disorders  and  the 
altered  knee  jerks  of  the  early  stage  of  the  disease  to  the 


124  A  TEXT-BOOK  OF  INSANITY 

contractions  and  bed-sores  of  its  final  stage,  physical 
symptoms  are  of  high  importance  throughout.  The 
question  is,  Are  these  physical  symptoms  produced  by 
the  very  sam^e  changes  in  the  brain  that  produce  the 
delirium,  or  do  they,  as  in  the  case  of  specific  fever,  own 
some  other  and  deeper  cause,  to  which  the  brain  change 
also  is  due  ?  The  puzzle  is  that  both  questions  may  be 
answered  in  the  affirmative.  The  whole  of  the  disorders, 
brain  change  and  all,  are  due  to  the  poison  of  syphilis, 
just  as  the  whole  of  the  disorders  in  delirious  small-pox, 
brain  change  and  all,  are  due  to  the  poison  of  small-pox  ; 
but  the  difference  is  that,  in  small-pox,  the  rash  on  the 
skin  and  the  other  symptoms  are  produced  directly  by 
the  local  action  of  the  poison  on  the  skin  and  other  parts 
displaying  the  symptoms,  while  in  general  paralysis  the 
whole  of  the  physical  symptoms  are  produced  in- 
directly by  the  action  of  the  poison  on  the  brain,  and  it 
is  the  impairment  of  the  trophic  and  other  functions  of 
the  brain  to  which  the  physical  symptoms  are  due.  In 
general  paralysis,  therefore,  all  the  symptoms  are  cor- 
related by  the  brain  disorder  ;  in  small-pox  we  must  go 
behind  the  brain  disorder  to  the  widespread  action  of  the 
poison  in  order  to  discover  the  correlating  agent.  Hence, 
general  paralysis  may  be  regarded  as  an  instance  of  the 
disease  insanity,  in  which  the  disorder  of  metabolism, 
which  I  say  is  part  of  the  disease,  is  unusually  profound, 
widespread,  and  severe. 

It  is  of  the  greatest  importance,  therefore,  in  dealing 
with  insanity,  to  remember  that  insanity  may  be  a 
symptom  or  a  disease  ;  and  it  is  expedient,  when  we  are 
speaking  of  disorder  of  conduct  and  mind  alone,  that  is  of 
the  symptom  insanity,  to  call  it  delirium,  or  some  other 
title  than  insanity,  and  to  reserve  the  name  insanity  for 
diseases.     Since,   however,   delirium  has  an  old  and 


SYMPTOM  AND  DISEASE  125 

prescriptive  right  to  characterise  that  peculiar  form  of 
the  symptom  that  occurs  in  specific  fevers  and  in  some 
other  bodily  diseases,  I  shall  here  call  the  symptom 
insanity  by  the  name  of  the  form  of  insanity,  and  the 
difierent  diseases  that  insanity  includes — for  it  does 
include  difierent  diseases — by  the  title  of  kinds  of 
insanity. 


CHAPTER  V 

FORMS   OF  INSANITY 
(insanity  the  symptom) 

A  FORM  of  insanity  is  therefore  a  correlated  couple  of 
disorder  of  conduct  expressing  disorder  of  mind,  or  of 
disorder  of  mind  expressed  in  disorder  of  conduct,  pro- 
vided the  disorder  is  not  recognised  as  disorder  by  the 
subject  of  it.  For  instance,  grievous  expression  and 
demeanour,  accompanied,  it  may  be,  by  lamentation, 
express  dysphoria,  or  misery  of  mind.  If  this  misery  is 
manifestly  unjustified  by  the  circumstances  in  which 
the  patient  is,  it  is  disorder  of  mind  ;  and  the  grievous 
expression  and  demeanour  which  express  the  disorder  of 
mind  are  disorder  of  conduct.  If  the  sufferer  recognises 
that  his  misery  is  unjustified  by  his  circumstances,  and 
looks  upon  it  as  disorder,  then,  although  it  is  disorder  of 
mind,  it  is  sane  disorder.  If,  however,  he  does  not 
recognise  that  it  is  unjustified,  and  especially  if  he 
attributes  his  misery  to  misfortunes  or  other  circum- 
stances that  are  imaginary,  and  for  which  there  is  no 
sufficient  evidence,  then  the  misery  is  insane  disorder  of 
mind,  and  the  grievous  demeanour  and  lamentation  are 
insane  disorders  of  conduct.  This  correlated  couple  of 
insane  disorder  of  mind  plus  the  insane  disorder  of 
conduct  that  expresses  it,  I  call  a  form  of  insanity.  The 
correlated  couple  may  also  be  called  a  symptom  of  dis- 
order of  the  brain. 

126 


MELANCHOLIA  127 

Of  course,  strictly  speaking,  the  disorder  of  mind  is 
not  a  symptom,  since  it  cannot  be  observed.  We  cannot 
observe  the  patient's  misery,  but  we  can  observe  the 
expression  of  it  in  his  conduct,  and  we  infer  so  directly 
from  this  expression  to  the  state  of  mind  that  it  ex- 
presses, that  we  may,  without  much  straining  of 
language,  speak  of  them  both  as  symptoms,  or  at  least 
of  the  combination  as  a  sjnnptom.  It  is  quite  clear  from 
the  language  used  by  many  ahenists  that  they  think 
they  do  observe  the  state  of  the  patient's  mind. 

Misery,  expressed  in  grievous  demeanour  and  un- 
justified by  the  patient's  circumstances,  is  called  by 
ahenists  melancholia,  and  this  word  is  a  good  example 
of  the  confusion  of  our  nomenclature,  and  of  the 
ideas  expressed  by  our  nomenclature.  These  are  some 
of  the  meanings  for  which  the  term  melancholia 
stands  : — 

1.  Unjustified  misery,  known  by  the  patient  to  be 
unjustified,  and  therefore  sane. 

1 2.  Unjustified  misery,  not  recognised  to  be  unjustified, 
and  therefore  insane. 

3.  Unjustified  misery  plus  the  expression  of  it  in 
demeanour  and  other  conduct. 

4.  Unjustified  misery  and  its  expression  plus  disorder 
of  brain. 

5.  Unjustified  misery,  together  with  its  expression  in 
conduct  and  the  disorder  of  brain  on  which  it  is  supposed 
to  depend,  plus  gastro-intestinal  and  other  bodily 
disorders. 

6.  Unjustified  misery  together  with  the  elements 
previously  mentioned,  or  some  of  them,  2^?W5  delusion 
and  its  expression.  ** 

7.  Some  or  all  of  the  previous  elements  plus  abase- 
ment. 


128  A  TEXT-BOOK  OF  INSANITY 

8.  Suicidal  conduct,  with  or  without  some  or  all  of 
the  elements  above  mentioned. 

9.  Silence  and  resistiveness. 

It  would  be  absurd  to  dispute,  and  I  do  not  dispute, 
that  it  is  useful,  and  indeed  necessary,  to  characterise 
definite  clinical  pictures  by  specific  terms  ;  but  I  protest 
against  the  application  of  a  single  term  to  such  a  hetero- 
geneous collection  of  difierent  disorders,  some  simple, 
some  very  complex  ;  some  sane,  others  insane  ;  some  of 
them  mere  symptoms,  others  complete  diseases.  Our 
nomenclature  is  to  a  great  extent  a  measure  of  the  stage 
to  which  our  thought  has  progressed,  and  as  long  as  our 
nomenclature  is  as  confused  as  this,  our  thought  will  be 
equally  confused. 

Although  when  mind  is  disordered,  the  disorder  is 
always  expressed  in  some  disorder  of  conduct,  and  but 
for  the  disorder  of  conduct  we  should  not  know  that 
disorder  of  mind  exists  ;  and  although  when  conduct  is 
disordered,  this  disorder  is  always  the  expression  of 
some  corresponding  disorder  of  mind  ;  yet  it  happens  in 
some  cases,  and  often  in  dysphoria,  that  we  infer  so 
directly  and  immediately  from  conduct  to  mind  that  we 
are  apt  to  forget  the  disorder  of  conduct,  and  to  con- 
centrate our  attention  on  the  mental  disorder  alone. 

In  other  cases,  as  in  excited  conduct  and  in  destructive 
conduct,  the  disorder  of  conduct  is  conspicuous,  and  it  is 
difficult  to  interpret,  or  to  infer  with  any  confidence, 
what  disorder  of  mind  is  expressed  by  the  disorder  of 
conduct.  In  such  cases  we  speak  of  the  insanity  as 
disorder  of  mind,  but  we  think  of  it  as  disorder  of 
conduct. 

In  a  third  class  of  cases  the  disorder  of  mind 
cannot  be  definitely  known  except  by  the  verbal 
confession    and    description    given    by    the    patient. 


FORMS  OF  INSANITY  129 

which,  of  course,  is  a  part  of  conduct ;  but  even 
then,  though  we  witness  disorder  of  other  parts  of 
conduct,  and  though  we  have  the  patient's  own  descrip- 
tion of  the  disorder,  or  some  of  it,  that  is  present  in  his 
mind,  yet  it  is  impossible  to  interpret  the  disorder  of 
conduct  by  the  disorder  of  mind,  or  to  connect  the  one 
with  the  other.  It  is  difficult  to  see,  for  instance,  what 
connection  there  can  be  between  exaltation  and  delu- 
sions of  grandeur  and  of  increased  consequence  on  the 
one  hand,  and  such  conduct  as  washing  the  face  in  the 
pan  of  the  water-closet  or  throwing  the  bed-clothes  out 
of  the  window.  No  doubt  these  acts  were  prompted  by 
some  other  disorder  of  mind  that  was  not  discoverable. 

Still,  when  allowance  has  been  made  for  these  difficult 
cases,  we  must  assume  that  every  disorder  of  conduct 
expresses  a  corresponding  disorder  of  mind  which 
prompts  it,  and  that  every  disorder  of  mind  finds 
expression  in  corresponding  disorder  of  conduct ;  and 
though  it  is  in  many  cases  difficult  to  trace  the  connec- 
tion between  the  one  disorder  and  the  other,  yet  in  a 
wide  range  of  cases  we  can  discern  a  connected  couple  of 
disorder  of  conduct  and  disorder  of  mind,  afiording  a 
symptom  of  a  more  or  less  hypothetical  disorder  of  brain. 

In  a  previous  chapter  I  showed  that  mind  is  divisible 
for  the  purposes  of  the  alienist  into  five  principal 
divisions  or  faculties : — ^Desire,  Will,  Feeling,  Thought, 
and  Memory,  and  the  first  four  of  these  are  further 
divisible  into  grades  or  evolutionary  levels,  and  having 
regard  to  the  further  division  of  Feeling  and  Thought 
into  subjective  and  objective  sides,  there  are  altogether 
five-and-twenty  departments,  in  any  of  which  mind  may 
be  disordered  ;  and  in  some  of  these  departments  mind 
may  be  disordered  in  various  ways.  Each  department 
was  taken  singly,  and  the  disorders  to  which  it  is 


130  A  TEXT-BOOK  OF  INSANITY 

subject  were  described,  but  the  several  departments 
of  raind  are  not,  as  a  rule,  disordered  singly.  Sometimes 
they  are  so,  and  instances  of  such  localised  disorders  are 
witnessed  in  simple  dysphoria,  sane  hallucination, 
imperative  idea,  excessive  hesitation,  facility,  obsession, 
vertigo,  claustrophobia,  and  other  disorders.  Usually, 
however,  the  disorder  implicates  more  than  one  level  of 
a  faculty,  it  may  be  more  than  one  faculty,  either  on  the 
same  or  on  different  levels,  and  some  disorders  are  so 
widespread  as  to  impUcate  every  level  of  every  faculty. 
In  describing  any  large  number  of  objects  of  the  same 
kind,  it  is  manifestly  desirable  to  begin  with  the  simplest 
and  gradually  proceed  to  the  most  complicated,  but  in 
the  case  of  disorders  of  conduct  and  mind,  that  which  is 
simplest  from  one  point  of  view  is  the  most  complicated 
when  viewed  in  the  reverse  direction,  and  vice  versa. 
In  other  words,  we  may  pay  attention  either  to  what 
is  taken  away  or  to  what  is  left.  The  less  the  area 
of  mind  that  is  disordered,  the  more  of  normal  mind 
remains,  and  the  cases  in  which  but  a  very  small  area  of 
mind  is  disordered  are,  from  one  point  of  view,  the 
simplest ;  but  these  have  always  appeared  the  most 
puzzling  and  the  most  difficult  to  account  for,  as  appears 
when  it  is  remembered  that  they  include  such  maladies  as 
imperative  idea,  obsession,  and  claustrophobia.  On  the 
other  hand,  the  greater  the  area  of  conduct  and  mind 
that  is  removed,  the  less  remains  as  an  object  of  study, 
and  such  maladies  as  stupor  and  coma,  in  which  every 
level  of  every  faculty  of  mind  and  conduct  is  abolished, 
are,  in  spite  of  the  extreme  extension  of  the  disorder,  the 
simplest  to  study,  because  little  or  nothing  remains  to 
observe.  Here  it  will  be  advisable  to  regard  those  cases 
as  simplest  in  which  the  disorder  is  most  limited, 
and  the  complementary  area  of  the  normal  largest,  for 


DISORDERS  OF  DESIRE  131 

these  have  been  described  in  the  last  chapter,  and  their 
description  forms  a  starting-point  for  that  of  the  more 
complicated  disorders.  In  each  case  I  shall  take  the 
leading  disorder,  the  most  conspicuous  disorder,  and 
show  what  other  disorders  are  commonly  associated 
with  it. 

I.   DISORDERS   OF  DESIRE 

When  these  are  primary,  they  are  usually  single,  that  is 
to  say,  they  are  uncomplicated  with  disorder  of  other 
faculties  or  of  other  levels  of  desire.  Keeping  always  in 
mind  that  no  disorder  of  mind  is  insane  unless  it  includes 
disorder  of  the  highest  level  of  thought,  so  that  the 
subject  of  it  is  unable  to  recognise  that  the  disorder  is 
disorder,  we  come  first,  on  the  lowest  level  of  desire, 
to  sexual  perversion.  This  is  undoubtedly  disorder  of 
mind,  but  with  equal  absence  of  doubt  it  is  not  insanity, 
for  it  is  uncomplicated,  and  unaccompanied  by  disorder 
of  the  highest  intellectual  level.  It  is  undoubtedly 
disease.  Should  it  then  be  punished  ?  Certainly  not. 
A  man  should  no  more  be  punished  for  experiencing  a 
desire  that  he  cannot  help  than  for  suffering  a  pain  in 
his  head  that  he  cannot  help.  We  ought  not  to  punish 
the  sexual  pervert  for  entertaining  a  morbid  desire — 
and  we  do  not  punish  him  for  it.  But  if  he  acts  in 
pursuance  of  his  desire  in  such  a  way  as  to  gratify  it, 
then  we  punish  him,  and  rightly,  granting  that  it  is 
expedient  for  the  welfare  of  society  that  such  acts 
should  be  punished.  It  is  right  that  he  should  now  be 
punished,  for  the  act  is  the  product  of  his  will,  to  which 
the  disease  does  not  extend. 

It  will  be  unnecessary  to  go  through  all  the  mani- 
festations of  morbid  desire,  since  these  have  been  suf- 
ficiently described  in  a  previous  chapter,  but  something 


132  A  TEXT-BOOK  OF  INSANITY 

must  be  said  about  defect  and  disorder  of  the  highest 
level  of  desires,  those,  namely,  that  affect  our  relations 
to  our  fellows.  Ninety-five  per  cent,  of  the  crimes  that 
are  investigated  by  the  courts  are  crimes  of  dishonesty  ; 
that  is  to  say,  they  are  due  to  the  improper  preponder- 
ance of  desires  of  the  upper  middle  level — desires  of 
acquisition  and  of  livelihood — over  those  social  desires 
for  the  welfare  of  others  and  the  good  of  the  community 
at  large  which  keep  honest  men  honest. 

It  is  often  said,  by  those  who  have  no  clear  notion  of 
what  crime  is  or  of  what  insanity  is,  that  all  crime  is  in- 
sane— that  criminality  is  a  disease  of  the  nature  of  in- 
sanity. There  are  those  who  hold  that  all  crime  is  ipso 
facto  insanity ;  but  I  do  not  know  that  anyone  who  holds 
this  opinion  has  any  clear  notion  of  what  he  means  by 
crime  or  of  what  he  means  by  insanity,  and  until  he  is  pre- 
pared with  some  sort  of  justification  for  his  opinion,  it  is 
scarcely  worth  while  to  discuss  it.  It  is  certain  that  the 
general  opinion,  which  holds  the  field,  which  has  pre- 
vailed among  all  nations  and  in  all  ages  of  which  we 
have  any  record,  is  that  insanity  and  crime  are  distinct ; 
and  if  anyone  holds  the  opposite  view,  the  onus  is  upon 
him  to  justify  his  opinion  and  prove  his  case.  Up  to  the 
present  he  has  made  no  attempt  to  do  so.  On  the  other 
hand,  there  are  some,  among  whom  I  reckon  myself, 
who  hold  that  there  are  such  things  as  moral  imbecility 
and  moral  insanity  ;  in  other  words,  that  there  are  not 
only  criminals  who  are  insane  and  criminal  acts  that  are 
insane — everyone  is  agreed  upon  that — but  that  there 
is  a  certain  form  of  criminality  that  is  insane,  although 
the  great  bulk  of  criminality  and  the  great  majority  of 
criminals  are  sane.  I  now  proceed  to  elucidate  these 
propositions  and  to  show  cause  why  they  should  be 
accepted. 


CRIME  IS  NOT  INSANITY  133 

Crime  consists  of  acts  that  are  destructive  or  detri- 
mental to  society,  and  arises  from  the  preponderance  of 
selfish  over  social  desires,  that  is  to  say,  of  the  preponder- 
ance of  desires  on  the  three  lower  levels  over  those  of 
the  highest  level,  which  should  prevail  over  the  lower 
whenever  they  are  in  conflict.  I  do  not  here  labour  to 
establish  this  theme,  which  I  have  treated  at  sufficient 
length  in  my  book  on  Criminal  Responsibility.  The 
doctrine  is  generally  accepted  as  true,  and  has  never,  as 
far  as  I  know,  been  contested.  Insanity,  on  the  other 
hand,  is  disorder  of  conduct  and  mind  of  a  certain  kind. 
No  doubt  criminal  conduct  may  be  called,  with  a  certain 
stretching  of  the  meaning  of  words,  disordered  conduct, 
but  even  if  it  were  disordered  conduct,  it  would  not 
necessarily  be  insane  conduct,  for,  as  already  stated 
with  repetition  that  is,  I  fear,  becoming  wearisome, 
disorder  of  conduct  and  mind  is  not  necessarily  insane. 
If  it  were,  the  reeling  and  clutching  of  thegiddy  man  would 
be  insane.  As  already  explained,  that  conduct  only  is 
insane  which  is  unregulated  by  the  highest  level  of 
intelligence.  Criminal  conduct  is  the  expression  of  a 
mind  in  which  the  highest  level  of  desire  is  defective  ; 
but  the  highest  level  of  desire  may  be  defective  without 
any  accompanying  defect  or  disorder  of  the  highest  level 
of  intellect,  and  unless  this  level  of  intellect  is  disordered 
there  is  no  insanity.  Criminal  conduct  may  be  not  only 
ingenious  in  a  very  high  degree,  witness  the  operations 
of  the  accomplished  burglar,  or  the  long  firm  expert,  but 
also  regulated  by  a  competent  wisdom  or  prudence  as 
far  as  the  welfare  of  the  criminal  himself  is  concerned. 
For  what  manner  of  man  is  the  criminal  ?  More  than 
ninety  per  cent,  of  recorded  crimes  are  crimes  of  dis- 
honesty. They  are  committed  by  persons  who  have  an 
aversion  to  steady  industry,  who  desire  to  enjoy  the 


134  A  TEXT-BOOK  OF  INSANITY 

fruits  of  labour  without  undergoing  labour  to  secure 
them,  who  estimate  the  risks  they  incur,  and  face  them 
for  the  sake  of  the  advantage  they  secure.  And  the 
advantage  is  often  great,  and  the  risk  not  prohibitive. 
We  hear  much  of  the  habitual  criminal,  who  is  convicted 
time  after  time,  and  spends  the  greater  part  of  his  life  in 
gaol  or  under  sentence ;  but  these  are  the  unskilful  or 
unsuccessful  practitioners,  and  for  very  good  reasons  we 
do  not  hear  of  the  successful  expert,  who  contrives,  not 
only  to  keep  out  of  prison,  but  to  accumulate  wealth, 
or  at  least  to  keep  himself  in  comfort  by  his  depredations. 
Crime  not  only  exists  but  is  increasing,  and  crimes  of 
dishonesty  would  scarcely  exist,  and  would  certainly  not 
increase,  if  they  were  uniformly  unprofitable.  In  the 
very  long  run,  and  if  we  take  into  account  the  necessity 
to  each  individual  of  preserving  the  community  of 
which  he  is  a  part,  and  the  tendency  of  crime  to  de- 
teriorate the  community,  no  doubt  there  is  unwisdom 
in  crime  ;  but  as  far  as  the  individual  himself  is  alone 
concerned,  there  is,  or  may  be,  no  unwisdom  in  crime. 
He  may,  by  a  life  of  crime,  achieve  a  degree  of  success  in 
preserving  his  own  life  and  securing  the  amenities  of 
life  that  he  could  not  achieve,  or  could  not  achieve  so 
quickly,  in  any  other  way.  Criminality  is  therefore  not 
inconsistent  with  a  good  development  of  wisdom,  or 
with  the  integrity  of  the  highest  level  of  intelligence ; 
in  other  words,  it  is  consistent  with  sanity. 

But  some  crimes  are  undoubtedly  insane.  What  these 
are,  I  need  not  here  discuss,  for  the  whole  subject  is 
thrashed  out  exhaustively  in  my  book  on  Criminal 
Responsibility,  but  here  I  may  point  out  that  not  only 
are  some  criminals  insane,  but  also  there  is  a  form  of 
criminality  that  is  itself  insane,  and  I  have  made  a 
certificate  of  lunacy,  stating,  as  facts  indicating  insanity, 


MORAL  IMBECILITY  135 

criminal  conduct  of  this  description.  Criminals  of  this 
type  are  criminals  from  birth,  and  the  peculiarity  of 
their  criminality  is  that  it  is  unprofitable.  They  are 
often — usually — of  good  birth,  and  of  good  prospects — 
and  good  abihties.  Ingenuity  or  cleverness  is  often  in 
them  so  highly  developed  as  to  mask  the  insanity  to  an 
unskilled  observer.  Their  crimes,  it  is  true,  are  often 
clumsy  enough,  but  their  subterfuges  to  escape  the 
consequences  of  their  crimes  are  often  extremely 
ingenious,  and  their  lies  have  a  plausibility  and  veri- 
similitude that  would  deceive  anyone  who  has  not  had 
experience  of  them.  The  quality  that  distinguishes  their 
criminality  and  marks  it  as  insane  is  the  conspicuous 
want  of  prudence  and  wisdom.  The  crimes  are  com- 
mitted often  for  gain  which  is  manifestly  not  worth  the 
risk,  often  for  objects  which  could  be  obtained  equally 
well  and  with  equal  ease  by  honest  measures,  and  are 
often  committed  T^dth  such  lack  of  precaution  as  renders 
speedy  detection  certain.  Moreover,  the  whole  crimin- 
ality is  unnecessary  and  supererogatory.  With  their 
birth,  their  start  in  life,  their  opportunities,  their  family 
influence,  their  education  and  social  advantages,  it 
would  be  easier  to  make  an  honest  living  than  to  make 
a  Hving  by  crime  ;  and  the  life  that  they  could  live 
honestly  would  be  far  more  advantageous  in  all  ways 
than  that  to  which  they  condemn  themselves.  Such 
criminality  is  insane,  and  is  insane  by  reason  of  the 
defect  in  the  highest  level  of  intellect, 

II.   DISORDERS   OF   ^^LL 

Of  these,  Obsession  is  almost  always  uncomplicated, 
at  least,  I  have  never  seen  a  case  in  which  any  other 
disorder  of  mind  except  hesitation  was  associated  with 


136  A  TEXT-BOOK  OF  INSANITY 

obsession.  It  is  never,  in  my  experience,  insane ;  for  I 
have  never  seen  a  case  in  which,  the  patient  did  not 
recognise  and  deplore  his  disorder,  and  do  his  best  to 
restrain  it  and  correct  it.  The  obsessed  are,  it  is  true, 
often  depressed,  but  the  depression  is  thoroughly 
justified  by  their  experience  of  their  malady,  and  is  in 
no  sense  abnormal. 

Morbid  impulsiveness,  on  the  other  hand,  is  always 
associated  with  insanity,  at  any  rate  at  the  time  the 
impulsive  act  is  committed.  In  some  cases,  especially 
those  in  which  the  impulsive  act  is  unsuccessfully 
suicidal,  the  patient  does  recognise  shortly  after  the 
commission  of  the  act,  that  it  was  insane  ;  but  he  never 
realises  this  at  the  time ;  and  in  most  cases  impulsive 
acts  are  utterly  irrational,  and  are  committed  by  persons 
already  certified  on  other  grounds  to  be  insane. 

Morbid  hesitation  and  morbid  vacillation  are  never,  in 
my  experience,  insane.  The  patient  always  recognises 
and  deplores  his  malady.  Morbid  hesitation  is  some- 
times accompanied  by  the  obsession  to  count,  as  has 
already  been  described,  but  this  is  the  only  disorder 
with  which  it  is  associated. 

Facility  occurs  as  a  symptom  both  in  the  sane  and  in 
the  insane. 

Stubbornness  never  occurs  except  as  the  most 
prominent  symptom  of  a  widespread  and  deep  insanity. 
The  obstinate  silence  of  the  patient  renders  it  difficult  to 
investigate  his  mind,  or  to  ascertain  with  any  confidence 
the  range  and  extent  of  the  disorder,  but  there  is  strong 
reason  to  suppose  that  the  three  uppermost  levels  of 
objective  intelligence  are  disordered,  and  possibly  the 
lowest  level,  that  of  perception,  also  is  disordered. 
Certainly  the  highest  level — Wisdom — is  gone,  for  the 
whole  conduct  of  the  patient,  regarded  from  the  point 


DISORDER  OF  SUBJECTIVE  FEELING    137 

of  view  of  his  own  welfare,  is  unwise  in  the  extreme. 
Cleverness  also  gives  scarcely  any  manifestation  of  its 
existence,  the  few  stratagems  and  subterfuges  of  the 
patient  being  childish  and  transparent.  It  is  the  third 
level  of  intelhgence,  however,  that  which  estimates  the 
beneficence  or  maleficence  of  surrounding  agents,  that 
is  most  impaired.  As  far  as  can  be  judged,  the  stubborn 
person  lives  in  a  pervading  atmosphere  at  first  of 
suspicion,  and  at  length  of  rooted  conviction  of  the 
animosity  and  mahgnity  of  all  around  him.  Only  by 
this  supposition  can  we  explain  his  extreme  recalcitrancy 
to  every  suggestion,  to  all  persuasion,  his  determination 
to  do  the  opposite  of  everything  that  he  is  advised,  and 
his  occasional  unprovoked  violence  to  those  around  him. 
The  natural  expression  of  suspicion  is  by  taciturnity,  and 
the  stubborn  are  taciturn  to  complete  silence. 

III.     DISORDER  OP  SUBJECTIVE  FEELING 

The  chief  disorders  of  this  faculty  are  on  the  lower 
middle  level,  and  consist  of  the  opposite  states  of 
dysphoria  and  euphoria. 

Dysphoria,  or  misery  in  various  degree,  is  perhaps  the 
most  frequent  and  most  widespread  of  all  disorders  of 
mind,  and  that  with  the  most  numerous  associations 
with  other  disorders.  As  previously  stated,  it  may  exist 
alone,  and  is  then,  of  course,  sane ;  and  a  transient 
depression  of  spirits,  usually  associated  with  some 
digestive  trouble,  is  one  of  the  commonest  of  mental 
disorders.  The  most  frequent  mental  accompaniment 
of  dysphoria  is  abasement,  or  underestimation  of  self, 
on  any  or  every  level — physical,  mental,  possessive,  or 
moral.  With  this  underestimation  on  the  subjective 
side  of  thought  there  often  goes  overestimation  of  the 


138  A  TEXT-BOOK  OF  INSANITY 

maleficent  influence  of  circumstances,  a  disorder  which 
may  afiect  any  level  of  objective  thought,  even  the 
lowest,  in  which  case  it  produces  terrifying  or  depressing 
hallucinations  and  illusions. 

In  consequence  of  the  universal  prevalence  of  the 
doctrine  that  insanity  and  disorder  of  mind  are  con- 
vertible terms,  it  is  necessary  to  emphasise  again  in  this 
place  that  depression  of  spirits  is  not  necessarily  insane. 

It  is,  of  course,  completely  normal  when  it  is  due  to  the 
appreciation  of  adverse  circumstances  that  really  exist, 
of  failures  and  disappointments  that  have  actually  been 
experienced  ;  but  when  quite  unjustified  by  circum- 
stances, it  is  still  not  insane,  though  it  is  disorder  of  mind, 
when  it  is  known  and  recognised  by  the  patient  who 
experiences  it  to  be  morbid.  Nor  is  it  necessarily  insane, 
nor  even  morbid,  when  it  accompanies  disorder  of  mind 
in  other  departments.  Persons  with  obsession,  or  with 
imperative  idea,  or  with  agoraphobia,  are  often  de- 
pressed, but  their  depression  is  a  normal  and  justified 
consequence  of  the  discomfort  and  inconvenience  which 
their  malady  inflicts  upon  them. 

When  disorder  of  mind  begins  in  dysphoria  and 
spreads,  the  departments  of  mind  next  involved  are 
usually  the  other  levels  of  intellect,  both  objective  and 
subjective.  Disorder  of  the  corresponding — the  lower 
middle — level  of  objective  thought  produces  misap- 
preciation  of  circumstances,  such  that  they  are  invested 
with  maleficent  and  terrifying  qualities  that  are  purely 
imaginary.  Spread  of  the  disorder  to  the  upper  middle 
level  of  the  same  faculty  gives  rise  to  delusions  of  past 
and  future  experiences  of  depressing  character ;  and 
invasion  of  the  highest  level  prevents  the  correction  of 
these  errors  by  the  judgment.  Invasion  of  subjective 
thought  results  in  abasement,  and  depreciation  of  some 


ABASEMENT  AND  SUICIDE  139 

or  all  of  the  powers  of  the  patient,  physical,  mental, 
possessive,  and  moral.  Dysphoria  is,  however,  some- 
times accompanied  by  a  very  peculiar  form  of  abase- 
ment which  paradoxically  partakes  of  the  nature  of 
exaltation.  The  patient  exalts  his  own  powers — for 
evil.  He  overestimates  his  influence  for  harm.  He 
believes  that  the  sin  with  which  he  debits  himself  will 
ensure,  not  only  his  own  damnation,  but  the  ruin  of  his 
family,  of  his  country,  it  may  be. of  the  whole  human 
race ;  that  his  financial  ruin  will  bring  penury  on  all 
connected  with  him ;  that  his  personal  uncleanliness 
contaminates  everything  he  touches  or  everything  he 
comes  near.  It  is  when  the  moral  worth  of  the  patient 
is  underestimated  by  himself,  when  he  erroneously 
attributes  to  himself  crime,  sin,  and  moral  worthlessness, 
that  the  disorder  spreads  into  the  lower  middle  level  of 
desire,  and  the  tendency  to  self-destruction,  self-mutila- 
tion, and  self-injury  appears.  In  my  experience,  which 
I  give  for  what  it  is  worth,  suicidal  desire  and  suicidal 
attempts  do  not  appear  unless  and  until  moral  abase- 
ment is  reached.  I  have  not  found  that  underestimation 
on  the  second  level,  that  is  to  say,  delusion  of  poverty,  of 
loss  of  consequence,  is  associated  with  the  desire  for 
death  unless  there  is  also  depreciation  of  the  moral 
character  ;  and  this  is  the  more  remarkable  since  the 
sane  motive  for  suicide  is  almost  always  pecuniary  ruin. 
If  this  exclusive  association  should  be  corroborated  by 
general  observation,  and  found  to  be  a  universal  rule, 
it  will  be  of  the  highest  cHnical  importance,  for  it  will 
enable  us  to  expect  attempts  at  suicide  in  cases  in  which 
no  intention  is  expressed,  and  it  will  free  our  minds  from 
anxiety  and  render  precautions  unnecessary  in  a  large 
number  of  cases  that  now  give  us  great  solicitude. 
AU  the  different  disorders  into  which  dysphoria  enters, 


140  A  TEXT-BOOK  OF  INSANITY 

and  some  others,  such  as  stubbornness,  are  lumped 
together  by  alienists  under  the  title  of  melancholia,  a 
name  that  comes  down  to  us  from  the  time  of  Hippo- 
crates, and  signifies  black  bile.  It  is,  perhaps,  fitting 
that  a  name  derived  from  an  extinct  pathology  should 
be  applied  to  an  agglomeration  of  disorders,  some  sane 
and  some  insane,  some  simple  and  others  extremely 
complex,  some  attended  by  excitement  and  others  by 
lethargy,  and  it  is  about  time  that  the  agglomeration 
was  analysed  into  its  component  parts  and  the  name  of 
it  discarded  for  ever. 

Dysphoria  is  expressed  in  conduct  by  a  sad  and 
grievous  demeanour,  which  is  the  only  feature  in  conduct 
common  to  all  cases.  In  certain  cases  other  features  are 
added,  the  most  frequent  of  which  are  lamentation,  more 
or  less  bitter,  and  self-accusation.  The  activity  of 
conduct  varies  much,  from  lethargy,  from  which  the 
patient  can  be  aroused  only  temporarily  and  with 
difficulty,  to  considerable  excitement,  which  is  always  of 
a  character  consonant  with  the  dysphoria,  and  is  dis- 
played in  pacing  up  and  down,  in  wringing  of  the  hands, 
in  loud  lamentations,  or  it  may  be  in  determined  effort 
at  self-destruction  or  self-mutilation. 

The  older  alienists  divided  madness  into  two  kinds, 
melancholia  and  mania ;  and  although  this  division  is 
no  longer  sustained,  yet  the  two  states  are  still  con- 
trasted and  considered  antithetic  of  each  other.  This 
view  is  absurd.  If  there  is  any  antithesis  to  dysphoria, 
the  only  element,  if  there  is  any  element,  common  to  all 
cases  of  melancholy,  it  is  euphoria,  the  antithetic  state 
of  unjustified  elation.  Mania,  as  far  as  it  means  any- 
thing definite,  which  is  not  very  far,  means  excited 
conduct,  or  over- action,  and  the  true  antithesis  of  over- 
action  i§  under-actjon,  or  lethargy.     Dysphoria  may, 


EUPHORIA  141 

as  has  been  said,  be  accompanied  and  expressed  by 
over-action,  and  therefore  cannot  be  antithetic  to  over- 
action,  even  if,  in  any  case,  a  disorder  of  mind  could 
properly  be  compared  with  a  phase  or  mode  of  con- 
duct. 

The  antithesis  of  dysphoria  is,  of  course,  euphoria,  or 
elation,  high  spirits,  gaiety,  which  may  be  justified  by 
the  favourable  circumstances  of  the  patient,  just  as  low 
spirits  may  be  justified  by  the  circumstances  of  the 
patient,  and  in  either  case  the  state  of  mind  is  wholly 
normal.  Like  dysphoria,  however,  euphoria  or  elation 
may  exist  without  any  justification  from  circumstances, 
and  when  the  circumstances,  truly  considered,  would 
rather  justify  unhappiness.  In  such  circumstances, 
elation  is  a  disorder  of  mind,  and  this  disorder  of  mind 
is  frequent.  Like  dysphoria,  morbid  elation  may  be 
sane  or  insane,  but  it  is  to  the  disadvantage  of  humanity 
that  morbid  but  sane  elation  is  very  much  less  frequent 
than  morbid  but  sane  dysphoria.  The  former  is  indeed 
rare.  It  is  natural  that  it  should  rarely  come  under  the 
notice  of  the  physician,  for  people  are  not  likely  to  seek 
relief  from  undue  happiness,  even  if  they  recognise  that 
it  is  undue  ;  a  case  has,  however,  come  under  my  own 
notice,  in  which  a  young  man  declared  that  he  could 
not  account  for  feeling  so  happy. 

There  is,  however,  a  pretty  common  case  of  euphoria 
w^hich  may  be  considered  morbid,  and  which  is,  at  any 
rate,  in  its  early  stage,  quite  sane,  and  that  is  the 
temporary  elation  that  is  produced  by  alcohol,  and  to 
some  degree  doubtless  by  opium,  and  other  drugs.  It 
is  in  order  to  experience  this  elation  that,  in  a  large 
number  of  cases,  alcohol  is  taken  to  excess  ;  and  there 
is  in  very  many  cases,  before  the  intellect  becomes  dulled, 
an  interval  in  which  an  euphoria,  which  is  well  known  to 


142  A  TEXT-BOOK  OF  INSANITY 

be  unjustified  by  circumstances,  is  experienced  by  the 
drinker. 

Such  uncomplicated  elation  is  exceptional,  however. 
Usually  elation  is  accompanied  by  exaltation,  by  which 
is  meant,  as  already  explained,  overestimation  of  one's 
own  powers  and  qualities,  physical,  mental,  or  moral. 
The  distinction  between  elation  and  exaltation  has  never 
hitherto  been  made,  partly  because  they  usually,  though, 
as  we  have  seen,  not  always,  occur  together,  and  partly 
because  psychological  analysis  of  the  disordered  mind 
has  never  hitherto  been  attempted.  The  exaltation 
that  accompanies  elation  is  less  often  confined  to  a 
single  level  of  subjective  thought,  or  self-estimation, 
than  the  abasement  that  accompanies  dysphoria. 
Abasement  is  often  limited  for  a  time,  or  throughout 
the  malady,  to  underestimation  of  possession,  and 
delusions  of  poverty  may  exist  for  years  unaccompanied 
by  underestimation  of  mental,  physical,  or  moral 
qualities  ;  but  overestimation  is  rarely  limited  to  one 
level.  The  megalomaniac  who  believes  that  he  pos- 
sesses millions  of  money  and  extravagant  titles, 
believes  also  that  he  has  superhuman  strength,  perhaps 
that  he  has  several  bodies,  hundreds  and  thousands  of 
children,  intellectual  genius  such  as  the  world  never 
saw,  and  moral  worth  unspeakably  great.  Even  the 
euphoria  of  drunkenness  is  pure  in  the  early  stage  only 
of  drunkenness.  As  the  drunkenness  progresses, 
exaltation  is  soon  added,  and  the  drunkard  boasts  of  the 
qualities,  physical  and  mental,  with  which  drink  invests 
him.  The  exaltation  of  drunkenness  rarely  extends, 
however,  to  the  upper  middle  level.  Drunkards  do  not 
often  exaggerate  their  wealth,  though  they  may  spend 
and  bet  recklessly  as  if  they  did.  Their  profligacy 
arises    not    so    much    from    overestimation    of    their 


EUPHORIA  AND  EXALTATION         143 

wealth  as  from  confusion  of  mind  and  recklessness, 
and  inability  to  realise  that  they  are  spending  beyond 
their  means. 

Objective  as  well  as  subjective  thought  is  usually 
disordered  in  euphoria  if  this  is  considerable.  It  is  on 
the  lower  middle  level  that  disorder  is  most  conspicuous, 
so  that  the  euphoric  overestimates  the  propitiousness 
and  good  fortune  of  his  circmnstances,  and  their  benefi- 
cence towards  him;  but  the  highest  and  the  upper 
middle  level  also  are  defective,  for  the  exalted  euphoric 
is  always  wanting  in  cleverness  and  ingenuity,  and  is 
sadly  lacking  in  wisdom.  He  is  quite  unable  to  order 
his  life  with  prudence,  and  is  invariably  insane. 

Objective  as  well  as  subjective  feehng  always  partakes 
in  the  disorder  in  exalted  euphoria.  Sympathetic  joy 
at  the  good  fortune  of  others  is  freely  expressed ; 
benevolence  is  boundless ;  and  gifts  are  scattered  in 
profusion  upon  all  and  sundry  ;  admiration  is  evoked  by 
quite  commonplace  spectacles ;  and  all  the  joyous 
emotions — freedom,  self-reliance,  power,  dignity — are 
expressed  to  the  full. 

Disorder  of  the  lowest  level  of  desire  is  a  frequent 
accompaniment  of  euphoria  with  exaltation,  and  persons 
so  affected  are  often  amorous  to  excess. 

Volition  also  shares  in  the  disorder,  though  not  very 
conspicuousl}^,  and  the  exalted  euphoric  is  usually  facile 
and  easy  to  manage,  though  he  may  be  subject  to  out- 
breaks of  rage,  which  are  usually  shortlived. 

Though  euphoria  is  nearly  always  accompanied  by 
exaltation,  and  euphoria,  when  considerable,  is  never 
seen  without  exaltation,  the  converse  is  not  true. 
Exaltation  is  often  seen  without  elation,  and  every 
large  asylum  contains  its  kings  and  queens  and  million- 
aires who  are  by  no  means  elated  at  their  exalted 


Ui  A  TEXT-BOOK  OF  INSANITY 

position  or  wealth,  but  pursue  their  menial  occupations 
with  contentment,  but  without  extravagant  joy. 

Exaltation  alone  may  exist  without  a  trace  of  excite- 
ment in  conduct,  but  exalted  euphoria  is,  as  long  as 
bodily  strength  is  maintained,  usually  accompanied  and 
expressed  by  over-action  in  conduct.  The  patient 
teems  with  plans  for  the  benefit  of  others  as  well  as  of 
himself,  and  in  his  endeavours  to  carry  out  these  plans 
he  exhibits  over-action  on  a  high  level  of  conduct.  He 
is  restless  and  animated ;  he  talks  incessantly  except 
when  he  is  writing,  and  he  writes  incessantly  except 
when  he  is  talking. 

IV.   OBJECTIVE  THOUGHT 

The  lowest  level  of  Objective  Thought  is  perception, 
and  the  disorders  of  perception,  illusion,  and  hallucina- 
tion have  already  been  described.  They  sometimes 
occur  alone,  without  any  other  mental  disorder,  and  are 
then,  of  course,  sane.  It  is  a  commonplace  among 
alienists  that  hallucination  indicates  deep  disorder,  and 
usually  irrecoverable  disorder,  of  mind,  and  is  present 
only  in  severe  cases  of  insanity.  This  is  a  mistake. 
Hallucination  or  illusion  may  occur  alone  without  any 
discoverable  disorder  of  any  other  department  of  mind, 
and  since  without  disorder  of  the  highest  level  of  thought 
there  is  no  insanity,  such  hallucinations  and  illusions  are 
not  insane.  The  subjects  of  them  know  and  appreciate 
quite  clearly  that  their  morbid  percepts  are  morbid,  that 
they  answer  to  no  objects  in  the  external  world,  and 
that  any  objects  that  they  think  they  perceive  are 
imaginary.  Indeed,  those  who  are  deeply  insane  usually 
recognise  a  difference  between  the  normal  and  the 
abnormal  percepts.  They  speak  of  their  hallucinatory 
percepts  as  *'  voices  "  and  sometimes  express  a  doubt  of 


SUSPICION  145 

their  reality.  When  other  disorder  of  mind  does 
accompany  hallucination,  this  disorder  may  be  of  the 
most  varied  character,  and  may  be  very  widespread. 
The  reason  why  hallucination  is  looked  upon  as  a  grave 
symptom  is  that,  being  a  disorder  of  the  lowest  level,  it 
naturally  appears  late  and  at  an  advanced  stage,  when 
the  disorder  has  begun  in  the  highest  level  and  has 
gradually  spread  downwards  until  the  lowest  level  is 
reached.  In  such  cases  it  is  a  serious  symptom,  for  in 
such  cases  it  means  that  the  disorder  has  struck  deep  ; 
but  when  it  occurs  as  an  early  symptom,  and  especially 
when  it  occurs  without  other  disorder,  it  has  no  such 
grave  significance. 

The  lower  middle  level  of  objective  thought  is  that  by 
which  we  estimate  the  beneficence  or  maleficence  of 
those  circumstances  which  the  level  next  below  acquaints 
us  with ;  and  when  that  function  of  estimation  is 
primarily  disordered,  the  disorder  is  always  in  the 
direction  of  exaggerating  the  maleficence  of  the  circum- 
stances. This  exaggerated  estimate  may  express  itself 
merely  in  suspicion,  or  may  develop  into  definite  beliefs 
of  malevolent  action,  either  of  certain  agents,  specified 
or  unspecified,  or  more  often  of  mysterious  agencies,  or 
it  may  be  of  circumstances  in  general. 

Suspicion,  like  other  attitudes  of  mind,  may  be 
justified  or  unjustified  by  circumstances,  and  in  the 
latter  case  may  be  sane  or  insane.  A  general  attitude  of 
suspicion  or  confidence  is,  in  the  normal,  a  matter  partly 
of  temperament,  partly  of  experience.  Some  persons 
are  by  nature  confiding  and  apt  to  impute  beneficence 
rather  than  maleficence  to  others  and  to  circumstances 
generally.  Some  have  been  well  treated  by  others  and 
by  fortune,  and  have  had  no  occasion  to  suspect ;  others 
have  been  betrayed,  ill-treated,  unfortunate,  and  expect 

L 


146  A  TEXT-BOOK  OF  INSANITY 

to  meet  in  the  future  experiences  similar  to  those  of  the 
past.  All  these  are  within  the  limits  of  the  normal. 
But  suspicion  may  be  carried  to  excess,  and  whether  it 
remains  within  the  limit  of  the  normal  or  surpasses  it 
is  a  matter  of  degree.  Those  who  see  in  every  stranger  a 
possible  enemy  do  but  reproduce  an  ancestral  attitude 
of  mind,  for  in  many  languages  the  name  for  a  stranger 
and  the  name  for  an  enemy  are  the  same.  When,  as  in 
this  case,  and  as  in  the  case  of  failure  of  memory,  the 
transition  from  the  normal  to  the  morbid  is  a  matter  of 
more  or  less,  it  is  not  possible  usually  to  draw  a  sharp 
line  between  the  two,  but  in  the  case  of  suspicion  we 
have  in  many  cases  the  aid  of  a  qualitative  difierence, 
for  suspicion  may  be  fastened  upon  circumstances  that 
plainly  cannot  be  maleficent,  or  that  cannot  be  male- 
ficent in  the  manner  that  is  suspected.  A  man  who 
suspects  that  he  is  robbed  by  some  person  whom  he  has 
never  seen,  and  of  whose  existence  he  has  no  evidence 
whatever,  exhibits  suspicion  which  is  insane  by  reason 
of  its  degree :  a  man  who  suspects  another  of  imparting 
diseases  to  him  from  a  distance  by  means  of  a  system  of 
mirrors  and  lenses,  shows  suspicion  which  is  insane  by 
reason  of  its  quality.  Robbery  is  a  possible  mode  of  ill- 
treatment  :  the  production  of  disease  from  a  distance 
by  means  of  mirrors  and  lenses  is  not. 

Insane  suspicion  rarely  exists  for  long  as  an  isolated 
disorder.  The  suspicion  usually  soon  becomes  con- 
firmed into  belief,  and  the  disorder  spreads  up  to  the 
higher  middle  level  and  invokes  the  aid  of  ingenuity  to 
concoct  beliefs  of  the  most  extraordinary  and  far- 
reaching  character.  Some  mysterious  agency — any- 
thing the  operation  of  which  is  to  the  patient  mysterious 
or  unfamiliar — steam,  electricity,  telephones.  X-rays, 
wireless  telegraphy,  mesmerism,  hypnotism,  or  what 


INSANE  SUSPICION  147 

not — is  invoked  to  account  for  the  occurrence  of  events 
untoward  to  the  patient,  and  of  bodily  uneasiness  that 
they  suSer,  and  in  addition,  suspicion  or  conviction,  as 
the  case  may  be,  fastens  upon  certain  persons,  real  or 
imaginary,  as  the  agents  who  utilise  these  means  of  injury. 

To  these  disorders  of  objective  thought  the  malady  is 
in  many  cases  confined;  but  in  many  other  cases  it 
spreads  across  to  the  upper  middle  level  of  subjective 
thought,  and  implicates  self- estimation  with  respect  to 
rights,  honours,  titles,  position,  and  perhaps  money. 
The  person  who  is  insanely  suspicious  of  hostile  agency 
often  attributes  the  hostility  to  the  fact,  which  soon 
becomes  a  fact  to  him,  that  he  is  entitled  to  some  high 
position  which  the  hostile  agents  are  keeping  him  out 
of.  He  is  heir  to  a  dukedom  or  a  throne,  or  is  the  rightful 
tenant  of  one  or  the  other,  and  is  deprived  of  them.  If 
the  over-estimation  of  self  came  first,  the  belief  that  he 
was  rightfully  entitled  to  a  certain  position  which  he 
has  sense  enough  to  know  he  does  not  actually  possess 
might  logically  lead  the  patient  to  the  belief  that  he  was 
being  wrongfully  deprived  of  them  by  some  hostile 
agent,  and  this  may  be  the  origin  of  the  suspicion  in 
certain  cases ;  but  when  intellect  is  disordered,  its 
deductions  are  not  necessarily  logical,  and  as  far  as  we 
can  judge  it  would  seem  that  in  some  cases  the  belief  in 
hostile  agency  comes  first,  and  the  belief  in  an  over- 
estimated self-importance  second. 

The  chief  modes  in  which  suspicion  is  expressed  in 
conduct  are  reticence,  reserve,  and  recalcitrancy,  and  on 
these  follow  precautions  against  the  dangers  that  are  im- 
agined, and  retaliation  on  those  who  are  suspected.  We 
find,  therefore,  that  the  paranoiac, — the  symptoms  just 
described  are  those  of  paranoia — is  reserved,  reticent, 
and  recalcitrant ;  that  is  to  say,  he  suspects,  but   he 


148  A  TEXT-BOOK  OF  INSANITY 

does  not  readily  express  his  suspicions ;  attempts  to 
draw  him  out  and  lead  him  to  express  them  are  apt  to 
deepen  his  suspicion  and  increase  his  reserve ;  and  he 
is  recalcitrant  to  advice.  He  sees  in  every  suggestion  a 
sinister  motive,  and  is  with  difficulty  persuaded  to  do 
things  that  are,  it  may  be,  obviously  proper  and  bene- 
ficial. In  paranoia  the  second  level  of  objective  thought 
— ingenuity  or  cleverness — though  it  is  disordered  in 
such  a  way  as  to  elaborate  delusion,  and  though  it  is 
usually  the  seat  of  confusion,  yet  may  retain  consider- 
able efficiency.  The  paranoiac  is  often  clever  and 
ingenious,  and  exhibits  his  cleverness  and  ingenuity  in 
elaborate  precautions  against  the  plots  that  he  believes 
are  being  contrived  against  him.  He  changes  his 
residence  furtively  and  frequently,  so  as  to  throw  his 
enemies  of!  his  track.  He  hides  himself.  He  appeals 
to  magistrates  and  other  persons  in  authority  for  pro- 
tection. At  length,  finding  all  precautions  fruitless,  and 
receiving  no  protection,  he  is  apt  to  retaliate  either  upon 
someone  to  whom  he  attributes  his  persecution,  or 
upon  someone  who  is,  he  thinks,  in  a  position  to  protect 
him  and  has  failed  to  do  so,  or  upon  anyone  in  a 
prominent  position,  for  the  purpose  of  drawing  atten- 
tion to  his  case. 

Such  are  the  manifestations  in  conduct  of  a  belief  in 
hostile  agency  when  the  belief  is  in  an  agency  that, 
however  hostile,  and  however  widespread,  is  yet  not 
universal.  The  paranoiac  imagines  usually  a  highly 
complicated  system  of  persecution  by  some  agency 
that  is  to  him  mysterious,  but  there  is  always  a  part, 
sometimes  a  large  part,  of  his  circumstances  that  is 
outside  the  system  of  persecution.  Though  there  are 
many  persons  of  whom  he  is  suspicious,  yet  there  are 
always  some  in  whom  he  has  confidence,  at  any  rate 


PARANOIA  AND  STUBBORNNESS       149 

temporary  confidence.  Though  he  is  reserved,  yet  by 
tact  and  judicious  handling  his  reserve  may  be  invaded. 
Though  he  is  recalcitrant  to  advice  and  persuasion,  his 
recalcitrancy  may  be  overcome.  Though  he  is  reticent 
and  with  difiiculty  drawn  into  revealing  his  suspicions, 
he  can  always  be  drawn,  and  is  then  apt  to  become 
voluble  about  them.  But  there  is  a  deeper  depth. 
Imagine  all  these  pecuUarities  exaggerated.  Imagine 
the  reserve  and  reticence  exaggerated  into  complete 
taciturnity ;  imagine  the  suspicion  and  the  belief  in 
hostile  agency  to  become  universal ;  imagine  the  con- 
fidence to  be  withheld  from  everyone ;  imagine  the 
recalcitrancy  to  increase  into  what  has  been  described 
on  a  previous  page  as  stubbornness  ;  and  we  have  a 
picture  of  the  malady  so  styled.  The  paranoiac  is 
reticent,  the  stubborn  is  dead  silent.  The  paranoiac  is 
recalcitrant,  the  stubborn  is  mulishly  resistive.  The 
paranoiac  trusts  but  few,  the  stubborn  trusts  no  one. 
No  matter  whence  or  from  whom  a  suggestion  comes, 
he  always  resents  and  resists  it,  and  if  possible  does  the 
opposite.  As  he  speaks  but  rarely  or  not  at  all,  it  is 
not  easy  to  investigate  the  state  of  his  mind  and  the 
behefs  that  he  entertains,  but  his  whole  conduct  and 
demeanour  indicate  that  he  is  convinced  of  the  hostility 
of  everyone  around  him.  There  is  no  evidence  that  he 
is  capable  of  imagining  the  highly  complicated  system 
of  persecution  in  which  the  paranoiac  believes.  His 
conduct  is  much  more  crude  and  simple  than  that  of 
the  paranoiac,  and  it  is  evident  that  his  mind  is  much 
more  deeply  affected,  but  it  is  affected  in  the  same 
direction.  His  imaginings,  as  far  as  we  can  penetrate 
them,  are  of  the  same  character,  but  they  are  on  a 
much  lower  level.  He  exhibits  no  cleverness,  no 
ingenuity.    When  he  retaliates  by  violence  upon  those 


150  A  TEXT-BOOK  OF  INSANITY 

about  him,  as  he  often  does,  his  retaliation  has  none  of 
the  elaboration  of  the  paranoiac.  Instead  of  an  assault 
with  fire-arms  or  other  weapons,  carefully  devised  and 
long  considered,  it  is  a  blow  with  the  fist ;  but  the  root 
elements  of  taciturnity,  recalcitrance,  and  retaliation 
are  the  same  in  both  cases,  and  we  cannot  doubt  that 
the  mental  disorder  in  both  cases  is  the  same  in  nature, 
though  difierent  in  degree,  and  consists  in  rooted  belief 
in  the  hostility  of  those  around  them. 

This  being  so,  it  would  seem  that  stubbornness  is  but 
a  more  advanced  stage  of  paranoia,  and  that  we  might 
expect  paranoia  to  merge  and  deepen  into  stubbornness 
as  the  case  proceeds,  and  the  invasion  of  the  brain 
becomes  more  profound.  This,  however,  does  not 
conform  with  clinical  experience.  Stubbornness  is  an 
acute  malady  :  paranoia  a  very  chronic  one.  However 
long  it  lasts,  and  however  severe  the  symptoms,  paranoia 
never,  in  my  experience,  merges  into  stubbornness. 
Indisputably  allied  as  they  are  in  nature,  and  due,  it 
cannot  be  doubted,  to  greater  and  less  degrees  of  the 
very  same  change  in  the  very  same  regions  of  the  brain, 
yet  clinically  they  seem  to  be  quite  distinct.  Stubborn- 
ness is  not  a  very  frequent  form  of  insanity,  and  when  it 
does  occur  is  often  fatal,  which  paranoia  never  is ;  but  it 
would  be  both  interesting  and  important  to  observe 
whether  the  cases  of  stubbornness  that  recover  do  not 
pass  through  a  stage  of  paranoia  on  the  way  to  recovery. 
It  would  be  odd  if  they  did  not.  As  far  as  my  observa- 
tion goes,  stubbornness  is  always  confused  with  melan- 
choly, and  has  never  been  discriminated  or  described 
except  in  this  book,  and  therefore  no  observations  on 
its  course  have  been  made  except  by  myself,  and  as  the 
malady  is  not  frequent,  the  cases  I  have  seen  have  been 
but  few. 


DISOKDERS  OF  CLEVERNESS  151 

Disorder  of  the  upper  middle  level  of  objective 
thought  is  coDimon  enough.  This  is  the  locus  of  the 
great  majority  of  delusions,  those  that  affect  the 
relations  of  the  patient  to  the  world  in  which  he  lives, 
and  such  delusions  may  be  combined  in  multitudinous 
ways  with  disorder  of  other  levels  of  objective  thought 
and  of  other  faculties,  or  maybe  combined  only  with  that 
defect  of  the  level  immediately  above  them  which  con- 
stitutes them  delusions.  Distinct  from  delusion  is 
confusion  or  mere  dullness,  defect  of  ingenuity  or  clever- 
ness, which  often  exists  ah  initio,  the  patient  never 
attaining  to  the  normal  standard,  and  often  is  a  degrada- 
tion from  a  normal  degree  that  has  been  attained,  but 
that  has  been  lost.  Insanity  in  which  there  is  not  some 
lack  of  cleverness  and  clearness  of  thought  is  rare,  and 
is  seen,  if  at  all,  only  in  the  case  of  the  "  sane  lunatic," 
or  clever  lunatic,  already  described.  In  every  other 
case  of  insanity  the  defect  or  disorder  of  the  highest 
level  of  objective  thought,  which  constitutes  the  in- 
sanity, spreads  down  to  a  gTeater  or  less  depth  in  the 
level  immediately  beneath,  and  produces  confusion  of 
thought,  or  inability  to  receive  and  appreciate  evidence 
contradictory  of  the  delusions.  In  many  cases,  as  in 
that  of  paranoia,  the  confusion  extends  beyond  what  is 
necessary  to  ignore  the  evidence  against  the  delusions, 
and  is  apparent  in  other  matters,  but  only  in  matters 
connected  with  the  delusions.  Deluded  persons  of  all 
classes  are  many  of  them  very  clever  in  matters  uncon- 
nected with  their  delusions,  so  much  so  that  it  is  a 
standing  wonder  that  they  should  be  so  incredibly 
stupid  in  matters  that  do  concern  their  delusions. 

As  already  explained,  it  is  disorder  of  the  highest 
level  of  thought — wisdom  or  prudence — that  constitutes 
insanity.    Disorder  of  mind  in  any  other  faculty  and 


152  A  TEXT-BOOK  OF  INSANITY 

on  either  level  is  sane  unless  and  until  it  is  combined 
with  such  disorder  of  the  highest  level  of  thought  as 
prevents  the  subject  from  knowing  and  recognising  that 
the  disorder  is  disorder,  and  we  have  seen  that  sane 
disorders  of  mind  are  numerous  enough.  There  are,  in 
fact,  several  disorders  of  mind  that  in  my  experience  are 
never  insane.  Most  people  would,  I  suppose,  admit 
that  giddiness  is  not  necessarily  insane,  but  then  most 
people,  alienists  as  well  as  others,  would,  I  suppose,  not 
admit  that  giddiness  is  disorder  of  mind.  To  such 
people  this  book  is  not  addressed.  Until  they  are  able 
to  distinguish  the  mental  from  the  physical,  anything 
that  is  said  here  will  be  of  no  service  to  them.  Agora- 
phobia is  not  very  rare,  and  claustrophobia  is  frequent 
enough,  but  I  have  never  seen  either  of  them  in  an 
insane  person,  and  there  is  no  reason  to  suppose  that 
they  are  akin  to  insanity.  The  same  may  be  said  of 
obsession  ;  but  it  is  curious  that  imperative  idea, 
which  is  so  similar  to  obsession  in  its  persistent  striving 
to  assert  itself  against  the  control  of  the  superior  level, 
does  sometimes,  though  in  my  experience  not  often, 
succeed  in  establishing  itself  and  becoming  a  delusion. 
The  idea,  such  as  that  of  a  man  that  he  is  pregnant, 
is  for  long  recognised  to  be  absurd  and  irrational,  and 
is  scorned  and  rejected,  but  at  long  last  it  is  accepted, 
and  becomes  delusive.  Various  'phobias,  such  as  the 
fear  of  dirt  and  of  contamination,  which  lead  the 
subjects  of  them  to  perpetual  washing  and  changes  of 
clothing,  are  sometimes  insane,  but  their  irrational 
character  is  in  other  cases  quite  recognised  by  the 
subjects  of  them,  and  the  same  is  true  sometimes  of 
what  appear  at  first  sight  to  be  delusions  of  poverty. 
The  patient  when  pressed  and  confronted  with  proof 
will  sometimes  admit,  "  I  hnoiv  I  am  not  ruined,  but  I 


DISORDERS  OF  SUBJECTIVE  THOUGHT   153 

feel  that  I  am."  In  other  words,  he  suffers,  not  from 
delusion,  but  from  imperative  idea,  which  may  or  may 
not  subsequently  become  delusion. 


V.    SUBJECTIVE   THOUGHT 

The  lowest  level  of  subjective  thought,  that  depart- 
ment of  thought  in  which  we  estimate  our  own  physical 
powers  and  structure,  is  not  very  infrequently  dis- 
ordered in  such  a  way  as  to  produce  what  may  be  called 
Somatic  delusions,  that  is  to  say,  delusions  with  respect 
to  the  composition  of  our  own  bodies.  Such  delusions 
as  that  the  legs  are  made  of  glass,  that  the  back  of  the 
head  has  been  removed,  that  the  brain  has  been  taken 
out  or  otherwise  tampered  with,  that  there  is  a  weasel 
in  the  stomach,  or  a  tapeworm  in  the  head,  are  common 
enough,  and  are  usually  isolated  disorders,  accompanied 
of  course  by  disorder  of  the  highest  level  of  thought,  or 
they  would  not  be  delusions  ;  accompanied  no  doubt  by 
disorder  of  the  second  level,  or  evidence  of  their  existence 
would  be  required  ;  but  otherwise  unaccompanied  by 
mental  disorder.  In  other  cases  they  are  but  features 
in  a  widespread  disorder.  Under  and  over- estimation 
of  the  physical  powers  are  always  parts  of  a  wide- 
spread disorder,  and  are  always  accompanied  by 
dysphoria  and  euphoria  respectively. 

The  second  level  of  subjective  thought  is  that  which 
concerns  our  estimation  of  our  own  mental  constitution 
and  powers,  and  here  again  we  must  distinguish  between 
sane  mistake  and  insane  delusion.  It  would  be  quite 
erroneous  to  suppose  that  all  the  bizarre  notions  about 
the  constitution  of  the  mind  that  we  find  in  text-books 
of  psychology  are  insane  delusions.  They  are  merely 
sane   mistakes,   and  though   some   of  them   may   be 


154  A  TEXT-BOOK  OF  INSANITY 

evidence  of  disorder  of  mind,  the  disorder  is  within  the 
pale  of  sanity.  It  is  otherwise,  however,  with  such 
notions  as  some  persons  entertain,  that  other  people  are 
thinking  their  thoughts,  or  controlling  their  thoughts 
or  their  wills  or  their  desires  or  feelings.  It  is  true  that 
there  is  a  considerable  body  of  persons  who  believe,  or 
profess  to  believe,  that  some  persons  can  communicate 
their  thoughts  to  other  persons  at  a  distance  from  them 
by  other  than  physical  means,  but  those  who  entertain 
this  belief  are  not  necessarily  insane.  They  do  not,  as 
the  insane  do,  reject  positive  evidence  that  tells  against 
their  belief :  they  merely  entertain  the  belief  on  no  or 
on  very  insufficient  evidence,  and  are  thus  less  irrational 
than  the  insane,  though  they  are  more  irrational  than 
the  behevers  in  witchcraft,  for  which  there  was  at  one 
time  a  great  deal  of  evidence  of  considerable  cogency, 
including  many  confessions  of  suspected  witches. 
Under  and  over- estimation  to  a  morbid  degree  of  the 
mental  powers  are,  like  those  of  the  physical  powers, 
combined  with  dysphoria  and  euphoria  respectively, 
and  are  parts  of  a  widespread  disorder. 

There  is,  however,  one  very  common  instance  of  over- 
estimation,  which  is  not  actually  insane  in  degree, 
though  it  borders  on  insanity  and  sometimes  oversteps 
the  line.  This  is  the  overweening  vanity  of  adolescence 
and  youth.  Young  people  within  a  few  years  on  either 
side  of  twenty  are  apt  to  entertain  a  confidence  in 
their  own  mental  abilities  and  judgment  which  is  quite 
unwarranted  by  the  academic  success  at  school  or  at 
college  which  they  may  have  achieved,  and  in  fact  their 
achievements,  even  of  this  small  kind,  are  not  usually 
considerable,  and  the  airs  they  give  themselves  and  the 
dogmatism  with  which  they  assert  their  opinions,  as  if 
they  were  of  importance,  show  a  strange  ignorance  of 


MORAL  IMBECILITY  155 

Lord  Bowen's  celebrated  dictum  that  we  are  none  of  us 
infallible,  not  even  the  youngest  of  us.  This  is  the 
normal,  or  quasi-normal  degree  of  a  mental  peculiarity 
that  sometimes  transcends  the  normal,  and  then  becomes 
a  familiar  type  of  adolescent  insanity. 

Disorder  of  the  upper  middle  level  of  subjective 
thought,  that  is  to  say,  mal- estimation  of  means, 
position  in  life,  rank,  titles,  and  so  forth,  is  not  com- 
patible with  sanity,  and  therefore  never  exists  as  an 
isolated  disorder.  It  may,  however,  exist  without  any 
other  disorder  except  that  of  the  highest  level  of  thought, 
which  renders  its  correction  impossible ;  and,  as  already 
stated,  exaltation  of  this  character  is  not  at  all  in- 
frequent. On  the  other  hand,  abasement  on  this  level 
is  never  seen  without  dysphoria  as  an  accompaniment. 

Mal- estimation  on  the  highest  level  of  subjective 
thought,  that  is  to  say,  mal- estimation  of  our  own 
moral  character  and  acts,  does  in  some  rare  cases  exist 
as  an  isolated  or  almost  isolated  malady,  and  very 
puzzling  such  cases  are.  There  are  persons  who  are 
born  apparently  without  the  rudiment  of  a  moral  sense 
with  respect  to  their  own  acts,  and  who  never  acquire 
one.  They  begin  to  steal  as  soon  as  they  have  pockets 
to  put  stolen  goods  into,  and  they  continue  their  maraud- 
ing throughout  life.  It  is  not  that  they  are  brought  up 
in  criminal  surroundings  and  never  have  a  chance  to 
learn  the  difierence  between  good  and  evil.  They  are 
of  gentle  birth,  and  have  the  same  bringing  up  and 
education  as  their  brothers  and  sisters  who  live  honour- 
able and  upright  lives.  Their  peculiarity  is  that  they 
do  not  recognise  the  turpitude  of  their  acts.  They 
recognise,  indeed,  that  stealing  is  frowned  upon,  and 
that  their  thefts,  if  discovered,  will  bring  them  into 
trouble  ;  and  therefore  they  steal  secretly  and  with 


156  A  TEXT-BOOK  OF  INSANITY 

precautions  against  discovery ;  but  their  precautions 
are  often  but  slight  and  ineffectual,  and  when  confronted 
with  their  crimes  they  exhibit  no  shame,  and  seem  to  be 
incapable  of  understanding  that  they  have  done  wrong. 
Punishment  they  regard  as  unjust  vindictiveness  and 
unmerited  injury,  and  resent  it  as  undeserved.  I  have 
said  that  the  defect  is  almost  isolated.  It  is  usually  not 
quite  an  isolated  defect,  for  the  precautions  against 
detection  are  often  so  flimsy  that  it  is  manifest  they 
must  be  ineffectual,  and  that  discovery  and  its  conse- 
quences must  speedily  follow  ;  and  this  shows  a  defect 
of  wisdom  or  prudence  so  great  that  it  raises  the  ques- 
tion, if  indeed  it  does  not  settle  the  question,  of  insanity 
in  the  ordinary  sense.  Moreover,  there  are  indications 
of  other  mental  disorders.  There  is  sometimes  a 
malignant  vindictiveness  against  those  relatives  who 
have  suffered  most  by  their  depredations  ;  and  who 
have  taken  endless  trouble  and  made  many  sacrifices 
to  keep  them  out  of  prison  and  to  save  them  from  the 
natural  consequences  of  their  misdeeds.  If  there  is 
such  a  being  as  an  "  instinctive  criminal "  persons  who 
satisfy  this  description  are  best  entitled  to  the  appel- 
lation. 

Children  who  steal  are  not  necessarily  of  the  kind  of 
born  criminal  just  described.  Many  children  steal 
repeatedly  in  spite  of  repeated  punishment  for  stealing, 
and  often  are  very  ingenious  in  their  thefts.  They  steal, 
however,  without  precaution  against  discovery ;  they 
steal  when  they  know  that  discovery  will  be  speedy 
and  punishment  sure ;  they  steal,  it  appears,  from 
weakness  of  will  to  resist  desire.  They  fully  know  and 
appreciate  the  turpitude  of  their  acts.  They  do  not, 
as  the  children  of  the  previous  class  do,  regard  them- 
selves as  innocent  victims  when  they  are  punished. 


DEFECTS  OF  MEMORY  157 

They  know  how  wrong  it  is  to  steal ;  but  they  cannot 
resist  temptation.  Unlike  the  children  of  the  previous 
class,  they  always,  in  my  experience,  grow  out  of  their 
thievish  proclivities,  and  grow  into  normal  men  and 
women. 

VI.  MEMORY 

Defect  of  memory,  even  when  distinctly  morbid  in 
degree,  is  not  necessarily  insane,  although  when  it  is 
extreme  it  must  impair  the  judgment,  by  reason  of  the 
impossibility  of  holding  together  the  two  ideas,  com- 
parison of  which  constitutes  judgment.  Less  degrees 
of  defect  of  memory  are  quite  compatible  with  sanity. 
The  common  senile  defect,  which  begins  with  difficulty 
of  recalling  proper  names,  then  extends  to  forgetfulness 
of  substantive  names,  and  gradually  extends  to  forget- 
fulness of  recent  daily  events,  together  with  over- 
recollection  of  the  events  of  a  time  long  past,  remains 
quite  sane  until  it  becomes  very  extreme,  and  in  its 
milder  degrees  is  quite  compatible  with  shrewd  business 
capacity,  and  not  infrequently  accompanies  it.  When 
the  defect  becomes  extreme,  it  necessarily  impairs  the 
judgment,  and  is  often  attended  by  petulance,  querulous- 
ness,  outbreaks  of  temper  and  of  childish  violence, 
which  show  that  the  limits  of  sanity  are  passed,  for 
they  arise  on  very  inadequate  occasion,  and  exhibit  a 
conspicuous  lack  of  appreciation  of  circumstances  and 
of  wisdom. 

The  other  main  defect  of  memory,  the  inability  to 
remember  at  the  right  time  things  that  have  to  be  done, 
is  also  quite  compatible  with  sanity,  for  the  subject  of  it 
usually  appreciates  and  deplores  his  defect,  and  seeks 
medical  advice  for  aid  to  overcome  it.  It  is  true  that  it 
may  be  an  early  symptom  of  brain  disease  which  subse- 


158  A  TEXT-BOOK  OF  INSANITY 

quently  becomes  profound,  and  deprives  the  patient 
of  sanity,  but  in  its  early  stage,  and  as  an  initial 
symptom,  it  is  by  no  means  necessarily  insane.  Its 
earliest  mental  concomitants  are  confusion  of  mind, 
dullness,  and  generally,  defect  of  cleverness  and  in- 
genuity ;  and  in  the  natural  progress  of  the  disease 
these  soon  become  accompanied  by  such  inability  to 
appreciate  circumstances  and  form  the  ordinary  adjust- 
ments of  prudence,  as  amounts  to  insanity. 

VII.   GENERAL  DISORDERS 

In  the  foregoing  accounts  some  one  disorder  of  mind 
has  been  taken  because  it  is  the  most  prominent  and 
conspicuous  disorder  present  in  the  case,  and  the  sub- 
ordinate disorders,  or  those  that  are  less  conspicuous, 
with  which  it  is  found  in  combination  have  been 
described  in  connection  with  it.  There  are,  however, 
other  disorders  of  mind  which  spread  over  the  whole 
mental  area,  affecting  all  the  mental  faculties  upon  some 
or  all  of  their  levels  with  such  uniformity  that  it  is 
impossible  to  select  any  department,  or  even  any  faculty 
of  mind,  as  more  prominently  or  more  conspicuously 
disordered  than  any  other.  These  disorders  demand 
separate  consideration. 

Anoia 

One  of  the  most  frequent  of  these  disorders  is  a  more 
or  less  uniform  obUteration  or  ablation  of  all  the 
faculties  of  mind,  proceeding  from  above  downwards, 
and  extending  in  different  cases  to  very  various  degrees, 
until,  when  the  limit  is  reached,  conduct  and  mind  are 
completely  abohshed,  and  that  state  is  reached  which  is 
known  as  coma.  Coma  is  not  usually  regarded  as 
insanity,  but  of  course  it  is  insanity,  or  it  includes 


ANOIA  159 

insanity.  In  spite  of  the  very  prominent  and  con- 
spicuous loss  of  conduct  and  mind,  coma  is  not  re- 
garded as  insanity  because  it  usually  comes  on  pre- 
cipitately, and  we  are  so  preoccupied  with  the  physical 
basis  of  the  coma  that  we  forget  its  other  relations.  But 
coma  does  not  always  come  on  precipitately,  and  when 
it  is  the  culmination  of  a  gradual  process  that  has  been 
going  on  for  months  and  years,  as  it  is,  for  instance,  in 
those  cases  of  general  paralysis  that  go  on  to  the  end, 
and  are  not  cut  short  by  inter- current  pneumonia  or 
other  disease,  we  see  clearly  that  it  is  insanity  pushed 
to  the  extreme.  Conduct  and  mind  have  been  gradually 
failing,  gradually  diminishing,  gradually  departing,  for 
months  and  years,  until  they  are  completely  lost ;  but 
the  final  loss  is  not  a  new  feature  in  the  case,  it  is  merely 
the  long-existing  feature  pushed  to  the  extreme  ;  and 
if  coma  is  insanity  when  it  is  the  culmination  of  a  process 
that  has  been  going  on  for  months  and  years,  equally  is 
it  insanity  when  it  occurs  suddenly. 

In  coma,  as  usually  pictured,  there  is  something  more 
than  loss  of  conduct  and  unconsciousness.  There  is 
besides,  at  any  rate  in  deep  coma,  universal  paralysis 
of  the  voluntary  muscles.  This  universal  paralysis  is 
quite  apart  from  any  local  paralysis  that  may  be  due 
to  a  local  lesion,  as  for  instance  unilateral  cerebral 
haemorrhage,  a  local  paralysis  which  remains  when  the 
general  paralysis  is  cleared  away.  This  universal 
paralysis  is  due  to  the  great  depth  to  which  the  lesion 
suddenly  implicates  the  central  nervous  system.  When, 
as  in  general  paralysis,  the  lesion  is  very  gradual  in  its 
reset,  the  universal  paralysis  is  replaced  by  universal 
spastic  contraction.  There  are  cases,  however,  in  which 
the  depth  of  implication  is  less  than  this  ;  in  which  the 
muscles  are  neither  paralysed  nor  spastic,  and  in  which 


160  A  TEXT-BOOK  OF  INSANITY 

some  rudiment  of  conduct  and  some  glimmering  of 
consciousness  still  remain.  In  such  cases  the  patient 
is  not  necessarily  prostrate.  He  may  be  able  to  sit  up, 
or  to  stand.  He  may  even  be  capable  of  a  few  voluntary 
movements.  He  does  not  pass  his  urine  and  faeces 
involuntarily  or  inappropriately.  If  he  is  shouted  at, 
we  may  get  some  response  from  him,  if  only  a  look  or  a 
movement.  If  pushed  along  he  does  not  fall,  but 
performs  a  shuffling  walk.  Such  is  the  clinical  picture 
of  a  case  of  deep  stupor.  Stupor  may  be  deeper  than 
this,  so  that  the  patient  does  not  even  walk  or  stand,  or 
it  may  be  shallower,  so  that  he  feeds  himself,  and  per- 
forms other  simple  acts  when  he  is  told  to  do  so  ;  but  in 
any  case  the  characteristic  of  stupor  is  simple  defect 
of  conduct  and  mind,  usually  deep  defect,  uniformly 
distributed  over  all  the  faculties  of  mind  and  all  the 
phases  of  conduct,  and  uncomplicated  with  over- 
action  on  any  level.  The  stuporose  patient  experiences 
neither  desire,  pleasure,  nor  pain,  and  exercises  neither 
volition  nor  thought,  except  on  the  lowest  levels.  As 
recovery  takes  place,  the  several  levels  gradually  resume 
their  functions  in  their  order  from  below  upwards,  until, 
when  recovery  is  complete,  wisdom  resumes  its  sway, 
the  moral  and  social  desires  and  feelings  are  again 
experienced,  and  volition  comes  into  full  force  once 
more. 

In  stupor,  the  defect  extends  to  the  very  lowest  level  in 
all  the  faculties.  Even  the  crude  sexual  desire  is  not 
felt,  even  the  most  trivial  vohtions  are  impossible, 
objects  are  scarcely  perceived,  impressions  scarcely 
produce  sensations,  even  the  crude  pains  of  bodily 
injury  may  be  unfelt ;  and  as  has  been  said,  there  is 
scarcely  any  conduct  of  any  grade.  In  a  far  larger 
number  of  cases  the  defect  of  conduct  and  mind  is  not 


ANOIA  161 

as  deep  as  tliis.    The  great  bulk  of  the  inmates  of  lunatic 
asylums    are   persons    who    are   known   as    ''  chronic 
dements."    They  are  persons  in  whom  the  highest  level 
of  all  the  mental  faculties  is  lost,  and  for  the  most  part 
the  second  level  also  is  gone.    The  third  level  may  or 
may  not  be  invaded,  and  the  lowest  level  of  all  is  usually 
intact.    Such  persons  display  no  social  conduct.    Their 
conduct  is  quite  selfish,  and  consideration  for  others  is 
no  part  of  their  mental  equipment".     Of  wisdom  they 
have  none.     So  incapable  are  they  of  directing  their 
conduct  in  the  major  affairs  of  life,  that  they  must  be 
placed  under  the  care  of  others,  and  have  these  things 
managed  for  them.    They  feel  neither  the  pleasures  of 
sympathy  nor  the  pains  of  remorse,  and  the  moral 
estimates  that  others  form  of  them  are  wholly  indifferent 
to  them.    On  the  second  level  the  faculties  are  almost 
equally  deficient.    They  are  as  destitute  of  the  desire  to 
earn  their  livelihood  as  they  are  of  capacity  to  do  so. 
They  are  as  impervious  to  beauty  as  they  are  to  disgust. 
To  the  charms  of  wealth,  of  social  standing,  of  power 
they  are  as  indifferent  as  they  are  to  poverty,  to  the 
manifestations  of  dislike  and  contempt.     Often  this 
defect  is  deep  enough  to  invade  the  third  level,  and 
render  them  insensible  to  common  dangers,  and  to  the 
fear  and  anger  that  common  dangers  and  crude  antagon- 
ism evoke  in  normal  persons.    Their  spirits  are  never 
raised  or  depressed.    It  may  be  that  the  defect  invades 
even  the  lowest  level,  so  that  they  become  insensible 
even  to  the  crude  pain  of  bodily  injury  and  their  sensa- 
tions are  dulled.     Precisely  the  same  defects  of  the 
same  varying  extent  may  be  discerned  in  those  who 
have  not,  indeed,  lost  the  uppermost  levels,  but  who 
have   never   acquired  them.     The   imbecile   and  the 
dement  are  mentally  on  a  par.    What  differences  they 

M 


162  A  TEXT-BOOK  OF  INSANITY 

manifest  are  due  partly  to  the  greater  activity  in  conduct 
of  the  young,  in  whom  imbecility  is  usually  seen,  and 
partly  to  the  more  irregular  extension  upward  in 
imbeciles  of  normal  acquirement.  The  imbecile  who  is 
generally  dull  and  amented  may  surprise  us  by  a  dis- 
proportionate development  of  some  isolated  faculty, 
such  as  music  or  calculation. 

Dementia — literally  unmindedness,  or  deprivation  or 
lessening  of  mind — may,  as  a  form  of  insanity,  be  of 
any  degree,  from  the  slight  blunting  of  intelligence  and 
feeling  and  the  slight  diminution  of  conduct  that  we  all 
experience  at  the  end  of  a  tiring  day  to  the  complete 
obliteration  of  mind  and  conduct  that  we  witness  in 
coma  and  in  the  deepest  depths  of  stupor.  The  title 
dementia  is  also  given  to  the  kind  of  insanity  in  which 
the  form  dementia  is  the  main  symptom,  and  is  limited 
by  the  Scotch  school  to  those  cases  of  dementia  that  are 
irrecoverable.  This  confusion  of  nomenclature  is  un- 
fortunate, and  leads  to  a  great  deal  of  confusion  of 
thought. 

In  every  case  of  insanity  of  every  sort,  kind,  and 
description  there  is  some  degree  of  unminding — some 
loss  or  defect  of  mind — and  therefore  some  degree  of 
the  form  dementia.  As  already  shown,  the  one  character- 
istic of  insanity  that  is  never  absent,  and  that  constitutes 
insanity,  is  loss  of  the  highest  level  of  thought,  with  of 
course  corresponding  loss  of  the  highest  level  of  conduct. 
This  defect  is  in  many  cases,  and  especially  in  acute 
insanity,  so  swamped  and  overborne  by  excess  of  activity 
on  a  lower  level,  that  the  defect  is  overlooked,  but  it  is 
always  there.  When  a  patient  is  ramping  and  raving, 
stripping  himself  and  tearing  up  his  clothes,  hammering 
at  the  walls  and  breaking  the  furniture,  or  when  he  is 
wringing  his  hands  and  lamenting  his  crimes  and  sins, 


ANOIA  163 

our  attention  is  so  much  absorbed  by  these  active 
manifestations  that  we  are  apt  to  overlook  and  forget  the 
loss  of  wisdom  and  prudence,  the  inability  to  appreciate 
circumstances  and  to  guide  conduct  aright,  that  are 
at  the  bottom  of  the  symptoms  and  are  the  funda- 
mental elements  in  the  malady ;  but  these  elements 
are  always  present,  these  qualities  are  always  absent, 
and  it  is  their  absence  that  constitutes  the  insanity. 
The  more  active  symptoms  are  but  the  consequences  of 
the  loss.  When  the  active  symptoms  subside,  they 
leave  the  defects  outstanding  as  the  most  conspicuous 
features  in  the  disease,  but  the  defects  were  there  all 
the  time.  They  are  not  new.  They  now  become 
apparent  by  the  subsidence  of  those  that  masked  them. 
When  I  have  pointed  out  that  these  defects  of  mind 
and  conduct,  to  which  the  name  of  dementia  is  given, 
exist  in  every  case  of  insanity,  I  have  been  met,  especially 
by  Scotch  critics,  with  the  reply  that  this  is  absurd, 
because  dementia  is  irrecoverable,  and  many  cases  of 
insanity  recover.  They  meant  by  dementia  a  kind  of 
insanity  :  I  meant  by  it  a  form  of  insanity  common  to 
every  kind.  In  order  to  remove  this  misunderstanding, 
I  now  call  the  defect  of  mind  and  conduct  that  consti- 
tutes insanity  by  the  name  of  Anoia,  a  name  that  has 
unfortunately  been  used  before  in  another  sense,  but 
that  has  not  been  generally  adopted  in  that  sense,  and 
that  is  in  fact  but  little  known.  In  fact  I  am  sure  that 
the  majority  of  my  readers  will  be  unfamiliar  with  it. 
By  anoia  I  mean,  then,  that  defect  of  conduct  and  mind 
that  begins  at  the  top,  in  the  highest  level,  and  may 
remain  limited  to  a  mere  shaving  off  that  level,  as  in 
the  case  of  the  clever  lunatic,  or  may  extend  down- 
ward to  any  depth  until  at  last  it  touches  the  bottom  in 
coma.    Whether  it  invades  a  person  who  has  reached 


164  A  TEXT-BOOK  OF  INSANITY 

the  full  stature  of  conduct  and  mind,  and  takes  some  of 
it  away,  or  whether  it  is  congenitally  absent  and  has 
never  been  attained,  makes  no  difference  to  the  form  of 
the  insanity.  It  is  still  anoia.  The  name  applies  to 
every  such  case,  for  the  deficiency  in  each  is  the 
same  except  in  degree  as  a  whole,  and  in  the  degree 
to  which  the  different  levels  are  invaded.  Thus  under- 
stood, anoia  of  some  degree  is  present  in  every  case 
of  insanity,  and  it  is  the  anoia  that  constitutes  the 
insanity. 

In  other  words,  the  real,  the  important,  the  crucial 
feature  in  every  case  of  insanity  is  defect.  In  no  case 
does  disease  make  a  real,  a  fruitful,  addition  to  function. 
The  affection  of  function  is  always  in  the  direction  of 
loss,  of  defect,  of  diminution.  In  inflammation,  tissue 
change  is  increased  in  activity,  it  is  true,  but  it  is 
carried  on  upon  a  lower  level.  There  is  increase  of 
process,  but  there  is  diminution  of  function.  In 
glycosuria  there  may  be  increased  production  of  sugar 
by  the  liver,  but  there  is  no  real  elevation  of  the 
function  of  this  organ,  and  the  general  functions  of  the 
body  are  not  increased,  but  diminished.  And  so  it  is  in 
active  insanity.  In  mania  there  is  great  increase  of 
activity ;  in  melancholia  and  in  exaltation  there  is 
great  increase  of  feeling ;  in  delusion  there  is  increase 
in  the  ability  of  mental  states  to  enter  into  coherent 
combinations.  But  none  of  these  states  of  increased 
activity  indicate  real  operative  increase  or  elevation  of 
function.  On  the  contrary,  they  are  accompanied  by, 
and  they  indicate,  diminution  of  function.  For  with 
all  the  vivacity  of  thought  that  obtains  in  mania,  there 
is  always  an  inability  to  appreciate  the  circumstances 
in  which  the  individual  is,  and  his  true  relations  to 
these  circumstances.     With  all  the  increased  activity 


ANOIA  165 

of  conduct,  the  conduct  is  on  a  lower  level ;  it  is  not, 
and  cannot  be,  adapted  to  the  circumstances,  for  the 
power  of  adapting  conduct  to  circumstances,  the 
highest  function  of  the  brain,  is  defective.  With  all 
the  increased  intensity  of  feeling,  with  the  depression 
or  the  exaltation,  there  is  still  the  mal-adjustment  of 
this  feeling  to  the  circumstances,  and  there  is  still  the 
inability  to  bring  the  feeling  into  correspondence  with 
the  circumstances.  And  the  important,  the  vital 
disorder,  is  not  so  much  the  increase  of  activity,  as  the 
degradation  of  activity  to  a  lower  level ;  is  not  so  much 
the  excess  as  the  defect ;  is  not  so  much  the  mania,  or 
the  melancholia,  or  the  exaltation,  or  the  delusion, 
as  the  inability  to  appreciate  the  mal-adjustment  of 
conduct  and  thought  and  feeling  to  circumstances,  and 
to  bring  about  readjustment.  So  that,  in  all  cases 
of  insanity,  the  real  and  important  aberration  is  not 
necessarily  the  most  conspicuous  feature — the  over- 
action — which  may  be  regarded  as  adventitious,  and  to 
a  certain  degTee  as  accidental,  but  the  degradation  of 
activity  to  a  lower  plane  ;  and  it  is  this  degradation 
that  is  indicated  by  the  term  "  anoia," 
.  Allowing  that  in  all  forms  of  insanity  this  degradation 
of  conduct  exists,  then  the  cHnical  kind  of  insanity  will 
depend  upon  whether  the  defect  is  simple — that  is  to 
say,  upon  whether  the  activity  of  mind  and  conduct 
are  merely  degraded  and  diminished,  and  upon  the 
lower  plane  to  which  they  are  reduced  no  excess  of 
activity  takes  place,  in  which  case  it  is  simple  anoia  ; 
or  upon  the  kind  and  degree  of  inferior  and  debased 
activity  that  goes  on  at  this  lower  level.  When  the 
debased  activity  is  marked  by  excess  of  feehng,  we  call 
it  melancholia  or  exaltation,  as  the  case  may  be  ;  when 
it  is  exhibited  jn  excess  of  low-grade  conduct,  we  call 


166  A  TEXT-BOOK  OF  INSANITY 

it  mania ;  when  it  occurs  in  the  formation  of  beliefs, 
we  call  it  delusional  insanity.  In  any  case  of  simple 
anoia,  over-action  may  occur  at  the  low  level  to  which 
the  nervous  organisation  is  reduced,  and  then  we  call 
it  a  case  of  dementia  with  outbreaks  of  excitement, 
or  of  dementia  with  delusions,  and  so  forth.  Even 
when  the  anoia  is  deep,  when  the  level  to  which  the 
nervous  organisation  has  been  degraded  is  very  low, 
some  over-action  upon  this  lower  plane  is  usual,  and 
then  we  witness  those  forms  of  anoia  in  which  the 
patient  is  excessively  voracious,  in  which  he  eats  all 
kinds  of  filth  and  rubbish  without  distinction  ;  in  which 
he  collects  stones  and  sticks  and  bits  of  string  and 
other  rubbish ;  in  which  he  tears  and  destroys  his 
clothing  and  anything  he  can  get  hold  of  ;  in  which  he 
exhibits  for  many  hours  every  day,  and  every  day  for 
years  together,  some  simple  and  inappropriate  form  of 
conduct ;  in  which  he  shouts  and  screams,  or  pats  his 
leg,  or  rubs  his  clothes  together  as  if  in  the  wash-tub, 
or  rocks  himself  backwards  and  forwards  in  his  chair,  or 
repeats  the  same  form  of  words. 

The  degrees  of  anoia  are  practically  infinite.  They 
range  from  the  trifling  decadence  of  intelligence,  feel- 
ing, and  conduct  that  is  exhibited  by  anyone  after 
an  enfeebling  illness,  or  at  the  end  of  a  tiring  day, 
down  to  the  almost  total  obliteration  of  consciousness 
and  movement  in  the  latest  stage  of  such  a  disease  as 
general  paralysis,  in  which  the  patient  lies  a  mere  log, 
insensible  to  all  that  is  passing  around  him,  passing 
his  motions  and  urine  as  he  lies,  allowing  the  flies  to 
walk  over  his  face  and  into  his  open  mouth  without 
showing  the  least  sign  of  disturbance,  indifferent  to 
the  sight  and  smell  of  food  when  placed  before  him, 
incompetent  even  to  chew  the  food  placed  in  hjs  mouthy 


GRADES  OF  ANOIA  1G7 

and  exhibiting  only  sufficient  intelligence  to  swallow 
the  pulp  with  which  he  is  fed. 

In  this  long  and  uniformly  diminishing  series  we 
may  mark  off  separate  grades  where  we  please,  and 
whatever  divisions  w^e  make  will  be  wholly  artificial ; 
but  there  is  a  practical  convenience  in  distinguishing 
between  grades  of  anoia,  and  the  first  grade  that  we 
may  distinguish  is  that  in  which  the  social  activities 
alone,  or  chiefly,  are  defective.  In  this  respect  all  the 
insane,  \Ndthout  exception,  are  deficient.  As  the  higher 
social  quahties  are  the  last  to  be  acquired,  so  they  are 
the  first  to  be  lost  when  complete  sanity  begins  to  fail. 
We  never  find  an  insane  person  who  is  quite  polite. 
Ceremonious  they  often  are  in  an  exaggerated  degree, 
but  polite,  in  the  sense  of  exhibiting  those  little 
benevolences  which  are  as  oil  in  the  running  of  the 
social  machine,  they  never  are.  Even  the  sanest  of  the 
insane  are  deficient  in  courtesy.  They  may  bow  you 
into  their  room  wdth  an  exaggerated  afiectation  of 
ceremony,  but  they  fail  to  offer  you  a  chair ;  or,  if 
they  go  as  far  as  this,  they  exhibit  their  want  of  civility 
by  engrossing  the  conversation,  and  in  talking  ex- 
clusively about  themselves ;  in  their  naive  boastfulness ; 
their  engrossment  in  their  own  affairs  ;  their  indiffer- 
ence to  the  little  ordinary  duties  of  hospitality  ;  in  the 
absence  of  all  effort  to  entertain.  In  the  next  gTade 
of  dementia  the  indifference  to  social  obligations  is 
greater.  The  subject  of  it  will  receive  you  in  his 
shirt-sleeves,  he  will  go  about  the  streets  in  his 
dressing-gown  and  slippers,  he  will  go  to  a  funeral  in 
a  shooting  suit.  If  a  woman,  she  will  be  indifferent  to 
her  personal  appearance,  be  untidy,  slovenly,  and  dirty 
in  her  dress,  will  go  about  with  tangled  hair,  loose 
stockings,  and  shoes  down  at  heel.    If  a  man,  he  swears 


168  A  TEXT-BOOK  OF  INSANITY 

freely  before  ladies  and  strangers,  and  introduces 
objectionable  topics  of  conversation  without  discerning 
any  impropriety  in  so  doing  ;  or  lie  may  go  further, 
and  introduce  loose  women,  perhaps  his  own  mistress, 
to  his  wife  and  daughters,  and  even  bring  her  to  live 
in  the  same  house,  obUvious  to  the  objectionable 
character  of  his  conduct.  He  loses  reticence,  and 
speaks  familiarly  of  his  family  affairs,  of  his  income,  of 
his  differences  with  his  wife,  of  his  son's  misconduct, 
and  his  daughter's  epilepsy,  before  strangers,  in  railway 
carriages,  in  hotel  smoking-rooms,  in  his  club.  If  a 
woman,  she  will  talk  with  similar  want  of  reticence  of 
her  confinements  and  miscarriages,  of  her  husband's 
unfaithfulness,  or  her  own  amours. 

The  grades  of  anoia  described  above  may  co-exist 
with  full  ability  to  earn  the  livelihood  and  administer 
the  means,  but  in  the  next  grade  these  modes  of 
conduct  also  are  affected,  and  the  patient  becomes 
either  incapable  of  appreciating  the  importance  of 
continuing  his  regular  employment  and  of  regulating 
his  expenditure  according  to  his  income ;  or,  while 
recognising  the  importance  of  doing  so,  incapable  of 
appreciating  what  his  income  is,  and  therefore  what 
his  expenditure  should  be ;  or  deficient  in  ability  to 
follow  his  employment.  In  conjunction  with  these 
defects  we  meet  with  many  forms  of  excessive  action 
upon  a  lower  level,  which  will  be  alluded  to  in  other 
connections. 

The  lowest  grade  of  anoia  is  exhibited  by  those 
who  have  not  only  wholly  lost  their  ability  to  ad- 
minister their  means,  but  who  are  deficient  also  in 
that  primitive  group  of  activities  by  which  existence 
is  preserved  from  day  to  day  and  from  hour  to  hour. 
If  their  food  is  not  brought  to  them,  they  will  make 


MANIA  169 

no  efiort  to  provide  it  for  themselves.  They  have 
not  sense  enouoh  to  come  in  out  of  the  rain.  If  the 
house  were  on  fire  they  would  not  know  which  way  to 
go  to  get  out  of  it,  even  if  it  occurred  to  them  that 
it  was  desirable  to  escape.  Conduct  is  reduced  to 
finding  the  way  from  the  bedroom  to  the  sitting- 
room,  from  the  fireside  to  the  meal-table,  and  back 
again  ;  or  even  this  modicum  of  intelhgence  is  lost. 
Even  in  this  lowest  grade  of  anoia  degrees  or  sub- 
grades  are  apparent.  The  most  intelligent  of  these 
anoiacs  are  clean  in  their  personal  habits.  The  next 
lower  grade  is  when  they  pass  their  urine  under  them, 
but  go  to  the  closet  to  defsecate.  Then  this  is  also  lost, 
and  their  motions  are  passed  in  their  clothes.  Then 
they  become  incapable  of  dressing  and  then  of  un- 
dressing themselves ;  and  the  last  acquirement  to  be 
lost  is  the  art  of  carrying  the  food  to  the  mouth  when 
it  is  placed  before  them.  Even  in  this  accomplishment 
there  are  degrees,  for  some  can  use  a  knife  and  fork, 
some  a  spoon  only,  and  last  of  all,  this  implement  is 
abandoned,  and  the  fact  that  fingers  were  made  before 
spoons  is  practically  exemplified,  since  their  use  is 
retained  longer. 

Thus  understood,  anoia  of  some  degree  is  present  in 
every  case  of  insanity,  and  it  is  anoia  that  constitutes 
insanity. 

Mania 

In  anoia,  we  concentrate,  our  attention  on  the  defect. 
It  is  the  loss  or  absence  of  a  part  of  conduct  and  mind 
that  constitutes  the  form  ;  but  defect  rarely  exists 
alone.  It  is  usually  accompanied  and  often  obscured, 
either  continuously  or  from  time  to  time,  by  over- 
action  on  a  lower  level.     The  removal  of  the  higher 


170  A  TEXT-BOOK  OF  INSANITY 

levels,  and  it  is  the  higher  levels  that  are  first  and  most 
defective  in  anoia,  removes  from  the  levels  beneath 
them  the  control  to  which  they  were  subject  by  the 
higher,  and  permits  the  lower  to  act  in  excess,  provided 
they  contain  the  store  of  energy  necessary  for  action. 
In  coma,  all  the  levels  are  placed  out  of  action,  and  there 
is  no  over-action,  except  perhaps  of  the  purely  vegetative 
functions.  Respiration,  for  instance,  may  be  exces- 
sive. When  the  anoia  is  deep,  but  is  not  so  deep  as  this, 
and  but  little  energy  is  left  in  store,  even  this  little  may 
be  expended  excessively,  and  we  see  that  idiots  and 
dements  indulge  to  excess  their  lower  appetites.  When, 
however,  abundance  of  energy  is  contained  in  the  lower 
levels  of  the  nervous  system,  and  the  control  of  the 
higher  levels  is  removed,  we  witness  over-action  in 
great  excess  ;  and  all  such  over-action  undirected  by 
wisdom  or  prudence  receives  the  common  name  of 
mania.  Mania  is  not  a  kind  of  insanity ;  it  is  not  a 
disease  ;  it  is  a  form  or  symptom  only,  and  may  exist 
in  many  diseases.  However  enormous  and  portentous 
activity  may  be,  even  if  it  reaches  the  superhuman 
activity  of  Napoleon  Buonaparte,  and  wears  out 
ministers,  secretaries,  amanuenses,  and  subordinates  of 
all  grades,  it  is  never  excessive  so  long  as  it  is  informed 
by  wisdom — so  long,  that  is  to  say,  as  the  highest  level 
of  mind  is  intact.  Only  when  the  highest  level  is  out 
of  action,  it  may  be  but  the  thinnest  film  removed 
from  its  surface,  can  over-action  be  properly  said  to 
exist.  The  question  at  once  presents  itself,  Why,  if 
over-action  results  from  loss  of  control,  and  the  higher 
levels  control  the  lower,  is  there  not  always  over-action 
when  the  higher  levels  are  destroyed,  as  in  dementia, 
or  in  abeyance,  as  in  stupor  ?  The  answer  is  not  far  to 
^eek.     The  nervous  system  is  an  apparatus  for  the 


OVER-ACTION  171 

storage  and  expenditure  of  motion,  and  each  level  can 
expend  only  up  to  the  amount  that  is  in  store.  If  it  is 
in  a  state  of  general  repletion,  and  if  then  control  is 
suddenly  removed,  motion  will  be  set  free  in  great  excess. 
If  control  is  removed  but  gradually,  time  will  be  given 
for  readjustment  to  take  place,  and  for  inferior  levels 
to  assume  the  function  of  inhibition,  and  in  this  case 
the  outburst  of  over- activity  will  be  kept  within  limits  ; 
and  if  control  is  removed  from  levels  that  have  little  or 
no  motion  in  store,  little  or  no  motion  can  escape. 
However  suddenly  we  draw  the  cork  of  a  bottle  of  ginger 
beer,  there  will  be  no  overflow  if  the  beer  is  flat.  In 
stupor,  the  central  nervous  system  appears  to  be 
emptied  of  its  store  of  motion,  and  its  capacity  of 
restorage  to  be  in  abeyance.  In  quiet  dementia  the 
head  of  pressure  is  but  low,  and  little  escapes  because 
there  is  little  within  ;  but  given  a  great  head  of  pressure, 
and  a  sudden  removal  of  control,  and  a  great  outburst 
of  excessive  activity  is  certain. 

Over-action  may  take  place  on  any  level  except  the 
very  highest.  The  description  of  the  "  sane  lunatic  " 
given  on  a  previous  page  is  a  description  of  moderate 
over-action  upon  a  high  level,  due  to  removal  of  the 
control  of  a  still  higher  level ;  but  instances  of  much 
greater  over-action — much  greater  excitement — on  the 
same  level  are  not  infrequent.  The  clever  lunatic  is  a 
busy  man.  He  is  seldom  idle,  and  keeps  his  time  pretty 
fully  occupied  ;  but  his  industry  is  methodical.  When 
he  is  engaged  upon  a  task  he  keeps  at  it  until  it  is  com- 
pleted ;  and  he  has  his  intervals  of  rest  and  recreation. 
But  the  sufierer  from  what  may  be  termed  high-level 
mania  knows  no  rest.  He  is  eagerly  and  incessantly 
active,  and  his  activity  knows  no  continuity  and  no 
patience.    He  is  engaged  in  a  dozen  pursuits  at  once^ 


172  A  TEXT-BOOK  OF  INSANITY 

and  he  follows  them  all  with  the  same  impatient  avidity. 
He  sleeps  little ;  he  is  down  before  anyone  else  in  the 
house  ;  he  bolts  his  meals  to  get  back  to  work  ;  he 
writes  innmnerable  letters,  he  sends  innumerable  tele- 
grams, he  makes  innumerable  appointments.  He  is  as 
full  of  schemes  as  an  egg  is  full  of  meat,  schemes  in  his 
profession  or  business,  schemes  for  the  reconstruction 
of  national  and  political  affairs,  schemes  of  social 
regeneration,  schemes  for  the  welfare  of  his  family  and 
friends,  for  rebuilding  his  house  and  resettling  his 
household  affairs — schemes  for  anything  and  every- 
thing, schemes  that  may  not  be  without  plausibility, 
but  that  are  vitiated  by  want  of  proportion  between 
ends  and  means,  if  not  by  total  want  of  practicability 
or  even  of  desirableness. 

Over-action  on  a  low  level  shows  itself  in  equal  eager- 
ness, activity,  and  versatility,  but  the  activity  is  crude, 
and  the  aims  are  immediate.  In  the  place  of  schemes 
for  future  benefit,  and  action  directed,  however  unskil- 
fully, towards  carrying  them  into  effect,  no  aim  can  be 
discovered  beyond  the  immediate  intention.  There  is 
shouting,  but  the  shouting  is  without  purpose  of  attract- 
ing attention  or  warning,  there  is  hammering  at  the 
door  and  walls,  but  without  the  purpose  of  escaping ; 
there  is  tearing  of  clothing  and  destruction  of  furniture, 
but  only  with  the  purpose  of  expending  energy.  There 
is  incessant  walking,  but  not  with  the  purpose  of 
arriving  anywhere.  There  is  abundant  over-action, 
but  it  is  over-action  on  a  low  level,  the  higher  levels 
being  in  abeyance.  Excitement  in  conduct  must  be 
presumed  to  correspond  with  excitement  of  mind  ;  and 
no  doubt  in  elaborate  over-action  on  a  high  level,  excite- 
ment of  mind  shows  through  the  excited  conduct  ;  but 
in  the  erude  low-Jevel  excitement  that  has  just  been 


EXCITEMENT  173 

described,  excitement  of  mind  is  inconspicuous  just 
because  so  much  of  mind  is  in  abeyance.  The  higher 
levels  are  altogether  out  of  action,  and  what  excitement 
there  is  is  on  so  low  a  level  that,  when  the  higher  levels 
resume  their  sway,  even  the  memory  of  it  is  lost.  It  is 
lost  because  on  these  higher  levels  there  was  no  excite- 
ment, and  therefore  there  can  be  in  them  no  memory 
of  excitement. 


CHAPTER  VI 

TYPES  OF  INSANITY 

So  far,  the  classification  has  extended  to  the  symptom 
only  of  insanity.  No  attempt  has  been  made  to  con- 
sider insanity  the  disease,  or  to  show  of  what  different 
diseases  insanity  consists.  This  is  the  task  that  must 
now  be  undertaken,  and  undertaken  with  all  the 
trepidity  and  circumspection  that  are  naturally  in- 
spired by  the  failure  of  innumerable  predecessors. 

It  was  said  at  the  beginning  of  the  last  chapter  that 
two  conditions  are  necessary  to  the  validity  of  a 
classification ;  first  that  the  things  to  be  classified 
must  be  delimited  and  separated  from  all  other  things, 
and  second  that  there  must  be  one  fundamentum 
divisionis  or  principle  of  division,  and  no  more,  for  each 
act  of  dividing.  It  is  now  to  be  added  that  there  is 
a  third  condition  that  must  be  satisfied  by  every  classifi- 
cation, if  it  is  to  be  of  any  value.  It  must  be  adapted 
to  its  purpose.  If  a  classification  satisfies  the  two 
conditions  mentioned  above,  it  will  be  a  valid  classifi- 
cation, but  a  classification,  even  though  completely  valid, 
may  be  completely  useless  for  the  purpose  in  hand.  A 
classification  of  coins  according  to  their  value  is  a  valid 
classification,  and  for  the  purpose  of  a  bank  cashier,  a 
useful  classification  ;  but  valid  as  it  is,  it  is  utterly 
useless  to  the  numismatist.  A  classification  of  coins 
according  to  their  date  is  a  valid  classification,  and  for 

174 


CLASSIFICATION  175 

the  purpose  of  a  numismatist  a  useful  classification, 
but  it  is  utterly  useless  to  the  bank  cashier.  So  the 
following  classification  of  cases  of  insanity  is  a  valid 
classification,  and  is  for  the  purpose  of  the  asylum 
manager  a  useful  classification  : — 


"&' 


Able-bodied 


tractable 
turbulent 


( epileptic. 
( not  epileptic. 
J  epileptic, 
[not  epileptic. 


Not  able-bodied- 


rfrail         /employable. 

\not  employable. 

fof  infectious  disease. 

1  of  non-infectious  disease. 


sick 


But  valid  as  this  classification  is,  it  is  utterly  useless  to 
the  alienist  who  desires  to  organise  his  knowledge  of 
insanity.  To  produce  a  valid  classification  is  not 
enough.  We  want  a  classification  that  shall  be  adapted 
to  its  purpose  ;  and  for  this  we  must  settle  for  what 
purpose  the  classification  is  desired.  Why  do  we  want 
to  classify  cases  of  insanity  ?  Why  do  we  want  generally 
to  classify  things  ?  Mainly  for  three  objects  :  To  aid 
description  ;  to  refieve  the  burden  on  our  memories  ; 
and  to  organise  our  knowledge.  The  two  former  may 
without  much  straining  be  included  in  the  latter. 
The  root  of  all  thought  and  the  root  of  all  knowledge 
is  comparison  ;  and  the  aim  of  comparison  is  to  discern 
likeness  and  unlikeness,  to  group  together  in  thought 
the  things  that  are  alike,  and  to  separate  in  thought  the 
things  that  are  unlike.  In  one  aspect,  all  thought  is 
classification  ;  all  knowledge  is  of  classified  things. 

To  classify  and  to  know  are,  from  one  aspect,  the 
same  ;  and  as  we  crave  to  know,  so  we  crave  to  classify. 


176  A  TEXT-BOOK  OF  INSANITY 

When  we  speak  of  a  classification  of  cases  of  insanity, 
we  usually  mean  a  classification,  not  for  the  purpose 
of  putting  like  cases  with  like  in  the  wards  of  an  asylum, 
but  for  the  purpose  of  thinking  together  of  those  that 
have  the  most  nurderous,  far-reaching,  fundamental, 
and  important  similarities,  and  separating  those  that 
have  corresponding  differences. 

Bodily  diseases  are  not  difficult  to  classify.  They  are 
classified  according  to  the  agent  that  produces  them, 
or  according  to  the  organ  that  is  first  and  most  affected  ; 
but  madness  cannot  be  thus  classified,  for  the  agent 
that  produces  it  is  in  most  cases  unknown,  and  the 
organ  first  and  most  affected  is  usually  the  same. 
There  are,  however,  bodily  diseases  which  we  cannot 
or  do  not  classify  thus.  The  agent  that  produces  gout 
is  unknown,  and  so  are  the  agents  that  produce  certain 
other  diseases  ;  and  we  do  not  classify  gout  as  a  disease 
of  the  big  toe,  though  this  is  the  organ  that  is  usually 
first  and  most  affected.  If  we  refer  to  our  definition  of 
a  disease — that  it  is  the  whole  of  the  correlated  disorders 
from  which  the  patient  suffers — we  shall  see  that  what 
we  have  in  our  mind  when  we  speak  of  diseases  and  of 
classifying  them  is  a  certain  clinical  picture  that  we 
actually  witness,  that  is  to  say,  always  a  correlated 
group  of  symptoms,  to  which  is  usually  added  disorder 
of  function,  known,  inferred,  or  postulated,  of  some 
organ,  on  which  disorder  all  the  symptoms  depend,  and 
by  which  they  are  correlated.  The  concept  of  the 
disease  is  not  complete  until  we  add  to  these  elements 
a  certain  course,  more  or  less  variable,  that  it  will  take, 
and,  when  possible,  the  cause  to  which  it  is  due.  The 
whole  of  these  elements,  or  as  many  of  them  as  we  can 
ascertain,  are  combined  into  a  single  concept  which  we 
call  a  disease.  All  that  is  strictly  necessary  to  our  concept 


CLASSIFICATION  177 

of  a  disease  is  a  group  of  symptoms  which  we  have 
reason  to  believe  are  correlated  together  by  some 
miderlying  disorder,  and  a  specific  course.  If  we  can 
assign  an  underlying  organic  disorder,  and  a  cause,  all 
the  better.  Our  concept  is  the  more  complete ;  but 
a  correlated  group  of  s3rmptoms  runriing  a  certain 
course  is  all  that  we  need  to  constitute  our  concept  of 
a  disease. 

Bodily  diseases  are  comparatively  easy  to  classify, 
because  the  symptoms  by  which  they  are  known  are 
all,  with  one  exception,  of  the  same  order.  With  the 
exception  of  pain,  they  are  all  physical  symptoms  that 
can  be  observed  ;  and  facts  of  one  order  are  not  difl6.cult 
to  classify.  But  the  symptoms  by  which  insanity  is 
known  are,  if  we  may  caU  mental  disorder  a  symptom, 
of  three  different  orders,  which  are  not  comparable 
inter  se.  The  S3niiptomatology  of  insanity  is  threefold 
• — physical,  mental,  and  praxic.  It  consists,  or  may 
consist,  of  disorders  of  the  body,  disorders  of  mind, 
and  disorders  of  conduct.  And  of  these,  disorders  of 
body  are  often  imperceptible  ;  disorders  of  mind  are 
never  perceptible,  and  it  may  be  difficult  or  impossible 
to  discover  their  exact  character ;  and  disorders  of 
conduct,  though  always  present,  are  often  elusive  and 
difficult  to  seize  and  to  describe  in  specffic  terms, 
and  are  often  overshadowed  by  the  preponderant  value 
of  the  mental  disorder,  which  clamours  insistently  for 
relief.  Hence  it  follows  that  some  cases  of  insanity,  for 
instance  mania,  are  recognised  and  described  by  the 
disorder  of  conduct ;  others,  such  as  melanchoHa,  by 
the  disorder  of  mind ;  and  yet  others,  such  as  the 
insanities  of  myxoedema,  of  cretinism,  and  of  acute 
specffic  fevers,  by  the  bodily  symptoms  ;  and  it  is  clear 
that   a   classffication   founded  upon  three   principles, 

N 


178  A  TEXT-BOOK  OF  INSANITY 

used  simultaneously  as  principles  of  first  division, 
cannot  be  a  valid  classification. 

There  is  yet  another  difficulty.  In  some  cases  of 
madness  there  is  a  definite  group  of  correlated  symptoms, 
the  like  of  which  we  see  again  and  again  in  successive 
cases,  which  runs  a  certain  course,  and  satisfies  all  the 
conditions  that  are  required  to  constitute  the  concept 
of  a  disease ;  but  in  a  large  number  of  cases  we  meet 
with  a  group  of  symptoms,  which,  since  they  are  dis- 
orders of  conduct  and  of  mind,  we  must  suppose  to  be 
correlated,  and  to  these  may  be  added  disorders  of 
bodily  health,  as  to  whose  correlation  with  the  others 
we  may  be  in  doubt ;  but  whether  they  are  so  correlated 
or  no,  the  whole  group  of  symptoms  is  like  nothing  we 
have  ever  seen  before,  or  is  like  one  fairly  constituted 
group  in  some  important  aspects,  and  like  another 
fairly  constituted  group  in  other  material  respects, 
and  perhaps  like  a  third  group  in  some  still  other 
material  respects.  Where  are  we  to  place  such  a  case  ? 
Two  or  three  diseases  have  equal  claims  to  accept  or 
to  reject  it,  and  if  we  constitute  each  such  case  a 
separate  disease,  the  accumulation  becomes  too  great 
for  the  mind  to  grasp,  and  classification  is  virtually 
abandoned. 

Still,  however  great  the  difficulties  may  be,  they 
must  be  met.  Insanity  must  be  classified,  or  our 
knowledge  is  at  a  standstill,  and  the  classification, 
to  be  a  valid  classification,  must  conform  to  rule ; 
that  is  to  say,  its  primary  groups  must  be  consti- 
tuted upon  one  single  fundamentum  divisionis  and  no 
more. 

As  far  as  I  know,  two  attempts  only  have  been  made 
to  classify  insanity  upon  a  single  principle.  The  first 
of  these  is  Sir  G.  Savage's  classification  according  to 


CLASSIFICATION  179 

the  age  at  which  it  occurs,  and  the  other  is  the  classifi- 
cation on  the  principle  of  dissolution. 

Sir  George  Savage's  classification  is  a  valid  classifica- 
tion, and  is  not  badly  adapted  for  a  certain  purpose, 
that,  namely,  of  readily  referring  to  its  place  in  the 
classification  those  cases  that  are  seen  in  practice  by 
the  physician  ;  but  as  what  is  sometimes  called  a 
scientific  classification,  that  is  to  say,  an  arrangement 
constituted  so  as  to  accord  with  important,  far-reaching, 
and  fundamental  resemblances  and  differences,  it  will 
not  do ;  for  though  the  symptoms  of  insanity  are 
probably  always  coloured  by  the  age  at  which  the 
insanity  appears,  yet  some  diseases  of  insanity,  such  as 
general  paralysis,  may  occur  at  any  age,  and  present 
no  material  difference  at  several  ages. 

To  the  orderly  mind,  a  classification  according  to 
the  principle  of  evolution  and  dissolution  is  most 
attractive,  and,  were  it  practicable,  would  undoubtedly 
be  preferred,  but  unfortunately  its  practicability  does 
not  extend  very  far.  According  to  such  a  classifica- 
tion, insanity  would  be  divided  first  into  cases  due  to 
imperfect  or  defective  evolution,  and  cases  due  to  dis- 
solution ;  and  so  far  the  scheme  is  practicable.  But 
the  division  of  the  insanities  due  to  dissolution  presents 
insurmountable  difficulties.  It  should  proceed  by 
dividing  insanities  due  to  uniform  or  general  dissolution 
from  those  due  to  local  or  partial  dissolution  ;  but  in 
our  experience  general  dissolution,  such  as  we  see  in 
stupor,  in  dementia,  and  in  general  paralysis,  begins 
locally,  and  not  often  in  the  same  locality  twice  running  ; 
and  the  cases  of  local  or  partial  dissolution  form  a 
heterogeneous  and  unclassifiable  group.  This  principle, 
therefore,  fascinating  as  it  is,  must  be  rejected,  except 
for  the  primary  division.    There  is  no  reason,  however, 


180  A  TEXT-BOOK  OF  INSANITY 

why  for  the  primary  division  it  should  not  be  utilised. 
It  is  after  this  stage  that  the  difficulties  begin. 

Since  what  we  are  now  endeavouring  to  classify 
are  diseases,  and  since  it  has  already  been  shown  that 
by  a  disease  we  mean  a  clinical  picture,  consisting  of  at 
least  a  group  of  correlated  symptoms,  it  is  natural,  and 
it  is  justifiable,  to  turn  to  the  clinical  pictures  and  ask 
whether  in  them  there  cannot  be  found  some  junda- 
mentum  divisionis  which  can  be  applied  to  the  dissolute 
class  of  cases  and  can  serve  to  divide  them  into  groups. 
Such  a  fundamentum  there  is,  and  although  it  does  not 
afford  a  very  sharp-cut  distinction  between  two  classes, 
it  is  easily  applied,  and  it  does  enable  us  to  divide  the 
dissolute  class  into  two,  and  the  division,  though  not 
absolute,  is  not  only  easily  made  in  a  great  number  of 
cases,  but  is  of  great  practical  importance.  It  is  the 
division  into  acute  insanity  and  chronic  insanity,  and 
I  must  explain  what  I  mean  by  these  terms. 

By  acute  insanity  I  mean  insanity  in  which  the 
symptoms  are  of  recent  onset,  are  intense,  and  are 
never  absent,  so  that  it  would  be  impossible  to  observe 
the  patient  for  even  a  few  moments  during  his  waking 
life  without  discovering  that  he  is  insane.  There  are 
many  cases  in  which  the  symptoms  are  intense  and 
remain  intense  for  years,  but  these  are  excluded  by  the 
definition  from  acute  insanity ;  and  there  are  many 
cases  in  which  the  symptoms  are  of  recent  origin  and 
intense,  but  which  we  know  will  last  for  years,  and  these 
are  in  a  sense  cases  of  chronic  insanity  ;  but  they  are 
for  the  time  cases  of  acute  insanity  in  the  sense  in 
which  that  term  is  used  here.  When  the  symptoms  are 
no  longer  of  recent  onset,  the  case  is  no  longer  one  of 
acute  insanity.  It  then  merges  into  chronicity.  To 
those  who  object  that  this  is  not  a  valid  division, 


CLASSIFICATION  181 

because  it  is  not  a  sharp  division,  I  reply  that  a  division 
may  be  quite  valid  though  it  is  not  sharp,  and  though 
we  may  not  be  able  to  indicate  with  accuracy  where  to 
put  the  dividing  line.  The  distinction  between  night 
and  day  is  quite  a  valid  distinction,  though  we  cannot 
draw  any  precise  dividing  line  between  them.  I  refuse 
to  be  tied  down  to  any  precise  number  of  days  as  the 
duration  of  recency,  but  if  I  were  compelled  to  give 
some  indication,  I  should  say  that  anything  less  than 
six  months  is  recent,  and  anything  more  than  six 
months  is  scarcely  recent. 

By  chronic  insanities  I  mean  all  those  that  are  not 
acute  according  to  this  definition.  It  is  evident,  there- 
fore, that  the  chronic  insanities  constitute  an  extremely 
heterogeneous  class,  and  that  many  of  them  have  once 
been  acute.  It  is  difficult,  and  would  be  scarcely  worth 
while,  to  divide  them  on  any  useful  principle,  but 
certain  of  them  must  be  described.  The  acute  insanities, 
however,  form  a  practically  well-defined  class,  and  one 
that  is  of  great  clinical  value.  For  clinical  purposes  it 
matters  little,  except  for  prognosis,  which  cannot  always 
be  made  with  any  confidence,  whether  an  acute  insanity 
will  be  transient,  or  whether  it  is  the  initial  stage  of  a 
chrc'uic  insanity  that  will  endure  for  years  or  for  life. 

It  may  seem  that  a  classification  by  dichotomy 
which  results  in  one  small  and  well-defined  class  and 
one  large,  heterogeneous  class,  insusceptible  of  further 
division,  cannot  be  a  very  useful  classification.  It  is 
useful,  however,  as  far  as  it  goes.  It  gives  us  one  class 
of  practical  value  which  can  be  studied  apart  from  the 
other.  It  selects  certain  cases  having  a  common 
quality,  and  enables  us  to  study  them  free  from  the 
confusion  and  embarrassment  of  the  remainder.  It  is 
analogous  to  a  classification  of  flowering  plants  into 


182  A  TEXT-BOOK  OF  INSANITY 

orchids  and  other  plants.  It  is  not  an  exhaustive 
classification,  but  it  does  distinguish  orchids  from  other 
plants,  and  enable  us  to  make  a  separate  study  of  them. 
So  this  mode  of  classifying  dissolute  insanity  enables 
us  to  distinguish  acute  insanity  from  other  insanity, 
to  make  a  special  study  of  it,  to  enumerate  the  features 
common  to  all  cases  of  acute  insanity,  and  to  sub- 
divide the  class  into  its  varieties.  Moreover,  the  two 
sub-types  of  chronic  insanity  that  will  be  described 
are  well-characterised  and  useful  tjrpes. 

ACUTE   INSANITY 

Acute  or  intense  insanity  is  insanity  of  recent  onset, 
in  which  the  symptoms  are  intense  in  that  they  are 
exaggerated  in  degree,  and  dissolution  proceeds  rapidly, 
until  conduct  becomes  crude,  and  manifestly,  often 
grossly,  insane,  so  insane  that  its  insanity  cannot  be 
missed  by  the  most  negligent  onlooker.  Acute  insanity 
is  susceptible  of  dichotomous  division  first  into  hyper- 
acute insanity  and  insanity  that  is  merely  acute. 
The  merely  acute  insanity  is  divisible  into  several 
varieties  according  to  the  feature,  mental  or  praxic, 
that  predominates.    They  are  as  follows  : — 

Acute  Insanity 

1.  Hyper-acute  insanity. 

2.  Acute  insanity. 

{a)  Excited  or  maniacal. 

(b)  Dysphoric  or  melancholic. 

(c)  Suicidal. 

(d)  Resistive  or  Stubborn. 

(e)  Sexual. 
(/)  Stuporose. 


ACUTE  DELIRIOUS  MANIA  183 

HYPER-ACUTE    INSANITY,    OR    ACUTE    DELIRIOUS    MANIA 

This  is  one  of  the  most  definite  and  clearly  dis- 
tinguished clinical  varieties,  as  distinguished  from 
forms,  of  insanity — one  of  the  few  varieties  of  in- 
sanity which  runs  a  very  definite  course.  No  other 
variety  of  insanitj^  exhibits  such  extreme  and  con- 
tinuous excitement  as  acute  delirious  mania.  Even 
in  acute  insanity  the  patient  has  his  moments  of 
tranquilUty  ;  has  snatches,  perhaps  prolonged  periods, 
of  sleep ;  will  occasionally  answer  questions  intelli- 
gently ;  will  regulate  his  conduct  with  some  reference, 
however  distorted,  to  surrounding  circumstances ; 
will  sometimes  recognise  his  friends,  and  will  have 
some  regard  to  the  decencies  of  life  ;  but  in  acute 
delirious  mania  the  ahenation  is  more  profomid.  The 
raving  is  continuous.  It  goes  on  incessantly,  day 
and  night,  the  whole  twenty-four  hours  round.  It 
is  quite  incoherent  and  meaningless,  a  torrent  of  un- 
intelligible utterance.  And  as  is  the  vocal  movement, 
so  are  the  other  bodily  movements.  The  restless 
activity  is  extreme  and  incessant ;  the  patient  roams 
about  with  ceaseless  restlessness,  he  is  never  still,  he 
never  lies  down,  he  never  sits  down,  he  is  always  on 
his  feet,  always  in  movement.  He  neither  eats  nor 
sleeps  ;  sometimes  he  will  drink,  sometimes  not ;  but 
in  any  case  he  never  eats  voluntarily,  and  is  with 
the  greatest  difficulty  induced  to  do  so.  The  length  of 
time  that  he  goes  entirely  without  sleep  is  astonishing. 
Day  after  day  and  night  after  night  he  keeps  up  his 
incessant  movement.  You  cannot  engage  his  attention  ; 
he  takes  no  notice  when  spoken  to.  He  is  indifierent 
whether  he  is  dressed  or  naked  ;  heat  and  cold  he  does 
not  notice  :    the  calls  of  nature  he  does  not  answer  ; 


184  A  TEXT-BOOK  OF  INSANITY 

his  bladder  becomes  full,  and  over-full,  until  his  urine 
dribbles  away.  Withal  his  temperature  is  raised  :  it  is 
seldom  much  raised,  but  it  is  two  or  three  degrees 
above  normal,  and  this  feature  alone  distinguishes  this 
from  almost  every  other  variety  of  insanity.  Such 
excessive  and  continuous  waste  of  tissue  and  of  energy 
cannot  endure  long  without  producing  exhaustion. 
After  a  few  days  of  this  extreme  restlessness  and  sleep- 
lessness, the  patient  is  no  longer  able  to  remain  on  his 
feet ;  he  sinks  to  the  ground,  but  still  he  continues  to 
rave  in  a  voice  hoarse  and  wellnigh  inaudible  from  in- 
cessant use  ;  still  he  continues  to  toss  about  his  weary 
limbs ;  and  when  this  stage  is  reached,  the  end  is  not 
far  off.  His  mouth  becomes  dry,  sordes  accumulate 
on  his  lips  and  teeth,  his  heart's  action  fails,  his  pulse 
flutters,  his  breathing  becomes  a  succession  of  sighs ; 
but  still  he  mutters  in  a  hoarse  whisper  his  unceasing 
babble,  until,  at  the  end  of  seven  or  eight  days  he  dies 
of  exhaustion.  Such  is  the  course  of  a  typical  case  of 
acute  delirious  mania,  the  "  brain  fever "  of  older 
writers,  the  most  rapid  and  most  terrible  variety  of 
insanity. 

It  affects  both  men  and  women,  and  usually  those 
who  are  in  the  prime  of  life — from  twenty-five  to  forty 
— and  is  usually  preceded  by  some  prolonged  and 
efficient  debilitating  occurrence,  such  as  an  exhausting 
illness,  deficiency  of  food,  rest,  and  sleep,  anxiety,  dis- 
appointment, or  excessive  intellectual  labour. 

Acute  delirious  mania  is  practically  always  fatal. 
If  a  case  is  so  mild  as  to  admit  of  recovery,  it  would 
be  one  of  acute  insanity  rather  than  of  acute  delirious 
mania.  As  to  treatment,  a  padded  room  is  essential. 
In  no  other  surroundings  can  the  restlessness  of  the 
patient  lead  to  so  little  bruising  and  other  injury. 


ACUTE  INSANITY  185 

Abundance  of  food  must  be  given  by  the  stomach 
tube,  and  mingled  with  it  should  be  given  brandy, 
strychnia,  and  large  doses  of  hypnotics — paraldehyde, 
sulphonal,  and  trional  being  the  best.  For  all  that 
we  can  do,  however,  the  patient  will  almost  surely  die  ; 
and  in  the  rare  cases  in  which  the  bodily  health  recovers, 
the  patient  remains  a  mental  wreck,  a  hopeless  dement 
for  the  rest  of  his  days. 

ACUTE   INSANITY 

The  boundary  between  this  and  the  previous  variety 
of  insanity  is  not  always  well  defined,  but  generally, 
the  whole  course  and  symptoms  of  acute  insanity  are 
less  acute,  less  rapid,  less  exaggerated  and  fulminating, 
than  those  of  acute  dehrious  mania ;  recovery  is  not 
infrequent ;  and  what  difierentiates  them  more  sharply 
is  that  in  the  latter  disease  the  form  of  insanity  is  always 
that  of  mania,  while  acute  insanity  is  of  several  types. 

The  causes  and  antecedents  of  acute  insanity  are 
those  of  insanity  in  general.  It  may  occur  at  any 
age  after  sixteen,  and  in  very  rare  cases  before  that 
age,  but  is  most  frequent  in  the  most  vigorous  period 
of  Hfe — from  twenty  to  forty-five. 

Acute  insanity  is  rapid,  sometimes  sudden,  in  its 
development.  The  very  first  thing  to  attract  attention 
and  to  indicate  insanity  may  be  a  determined  attempt 
at  suicide — a  leap  from  a  window,  a  cut  throat,  or  a 
dose  of  poison,  or  it  may  be  some  outrageous  or  violent 
act  directed  against  other  people.  But  usually  there 
is  some  warning  of  what  is  going  to  happen.  For 
days,  or  even  weeks,  beforehand,  the  patient  sleeps 
little,  dreams  much  and  vividly,  eats  little,  finds  himself 
unable  to  attend  to  his  business,  feels  ill,  and  perhaps 
seeks  medical  advice.    Headache  is  rare,  but  often  the 


186  A  TEXT-BOOK  OF  INSANITY 

mind  is  confused,  and  the  patient  dreads  lest  he  should 
be  going  out  of  his  mind  ;  or  he  gets  restless,  talks  too 
much,  pays  too  many  visits,  writes  unnecessary  letters, 
sends  unnecessary  telegrams,  neglects  or  mismanages 
his  own  business,  and  meddles  with  that  of  everyone 
else. 

After  a  few  hours,  days,  or  weeks  of  these  initial 
symptoms,  the  disease  becomes  fully  established,  and 
then  exhibits  several  forms  distinguished  by  the  follow- 
ing characters : — 

(a)  Excited  or  Maniacal 

In  the  first  form  the  patient  is  excited — that  is  to 
say,  his  movements  are  in  excess  ;  he  talks  with  rapid 
fluency  and  disconnectedly ;  he  utters  sometimes  a 
stream,  of  words  in  which  each  suggests  the  next  by 
sound  or  meaning,  but  which  are  not  connected  into 
sentences,  such  as  "  window,  wind,  blow,  thrashing, 
smashing,"  or  they  may  be  connected  into  sentences 
which  are  similarly  irrelevant  to  each  other,  as  "  open 
the  vdndow,  give  me  a  glass,  drink  your  brandy,  isn't 
he  handy  ?  what  a  dandy !  fine  feathers  make  fine 
birds,"  etc.  Together  with  verbal  utterance,  other 
movements  are  in  excess,  and  are  similarly  disconnected. 
The  patient  roams  about  the  room,  he  rushes  to  the 
door  or  the  window,  he  picks  up  every  movable  object 
and  throws  it  down  again,  or  throws  it  about  the 
room,  or  converts  it  to  some  use  for  which  it  was  never 
intended.  He  upsets  the  water- jug  and  the  chamber- 
pot, he  overturns  the  furniture,  he  breaks  the  windows, 
he  throws  the  chairs  about,  he  assaults  those  who 
endeavour  to  control  him,  he  tears  his  clothes  off,  he 
or  she  swears,  blasphemes,  and  talks  obscenely ;  and 
all  this  he  does,  not  with  any  settled  or  intelligent  or 


ACUTE   INSANITY  187 

enduring  purpose,  but  aimlessly,  erratically,  and  out  of 
the  mere  exuberance  of  his  energy. 

(b)  Depressed  or  Melancholic 

A  second  type  is  the  melancholic.  In  this  type  the 
activity  is  less,  and  there  is  a  dominant  delusion. 
The  patient  believes  that  he  is  ruined,  or  that  he  is 
damned,  or  that  he  has  some  frightful  bodily  disease, 
or  that  he  is  morally  a  hopeless  outcast,  and  to  his 
belief  he  gives  utterance  all  day  long.  He  is  usually 
still  over-active,  though  his  over-activity  is  less.  But 
he  does  not  sit  down,  he  does  not  rest ;  he  shuffles 
about  the  whole  day  long,  giving  vent,  not  with  shouts 
and  outcries,  as  in  the  previous  type,  but  in  a  mutter- 
ing, plaintive,  miserable  voice,  to  his  conviction  of 
his  own  ruin,  his  unworthiness,  his  incapacity.  He 
weeps,  he  moans,  he  wrings  his  hands,  he  tears  his 
hair,  he  beats  his  breast ;  he  importunes  you  for  a  ray 
of  hope,  a  glimmer  of  comfort ;  but  he  refuses  to  be 
comforted.  He  repeats  the  same  formula  over  and  over 
again  a  thousand  times  a  day  :  "  Oh  !  my  poor  soul." 
*'  I  am  so  wicked  !  "  "I  can't  pay  you  !  "  "  My  poor 
wife  and  children  !  "  ^' Oh  !  dear;  oh!  dear."  *' Oh  ! 
my  God,"  and  so  forth.  He  is  less  inclined  to  the  im- 
pulsive outbreaks  that  are  so  common  in  the  previous 
type,  but  he  is  very  likely  to  commit  suicide,  and  he 
is  more  persistent  and  obstinate  in  his  refusal  of  food, 
while  he  is  less  neglectful  of  personal  cleanliness  and 
less  apt  to  pass  his  motions  and  water  beneath  him. 

(c)  Suicidal 
Acute  insanity  of  suicidal  type  often  displays  as  much 
restlessness  and  over-activity  as  is  seen  in  the  first  type 
— that  of  acute  mania.    In  every  form  of  acute  insanity 


188  A  TEXT-BOOK  OF  INSANITY 

attempts  at  suicide  are  common  events,  but  in  this  form 
the  whole  attention  and  energy  are  concentrated  upon 
the  single  purpose  of  suicide.  The  sufferer  from  acute 
mania  will  try  to  jump  out  of  the  window,  or  will  take 
up  a  knife  or  a  razor  and  cut  himself  with  it,  not,  as  far 
as  can  be  judged,  with  any  deliberate  intention  of 
suicide,  or  of  anything  else,  but  out  of  pure  restlessness 
and  meddlesomeness,  combined  with  inability  to  appre- 
ciate the  nature  and  quality  of  his  acts.  In  this,  as  in 
every  other  type  of  acute  insanity,  there  is  sure  to  be, 
at  some  time,  refusal  of  food,  but  the  refusal  does  not 
appear  to  be  the  expression  of  any  deliberate  intention 
of  suicide.  But  in  this  third  variety  the  whole  power 
of  the  mind  is  absorbed  in,  and  devoted  to,  the  single 
object  of  suicide.  The  mind  is  far  more  alert  than  in 
the  other  types  ;  the  power  of  adapting  means  to  ends 
is  retained  to  a  far  greater  extent ;  and  the  end  which 
is  sought  with  inflexible  determination,  and  with  the 
most  flexible  adaptation  of  means,  is  suicide.  To  effect 
this  end  they  are  continually  on  the  watch.  In  every 
object  they  see  a  possible  means,  and  they  set  them- 
selves with  much  ingenious  contrivance  to  reach  it, 
and  possess  it.  They  will  promise  to  eat  if  they  may 
eat  by  themselves,  hoping  thereby  to  be  left  alone. 
They  will  break  glass  and  crockery  to  get  a  cutting 
instrument ;  they  will  ravel  out  the  threads  of  their 
clothing  to  make  a  cord  which  they  can  tie  round  the 
throat ;  they  will  swallow  anything  that  seems  un- 
wholesome ;  will  bite  a  piece  out  of  a  tumbler  or  a  cup, 
and  try  to  swallow  the  fragment ;  will  batter  the  head 
against  the  wall  or  floor,  and  try  by  the  most  unusual 
as  well  as  by  the  most  obvious  means  to  effect  their 
purpose.  If  they  find  suicide  impracticable,  or  while 
they  are  waiting  for  a  favourable  chance  to  efiect  it, 


ACUTE  INSANITY  189 

they  will  occupy  the  time  with  efforts  to  reduce  their 
comfort  and  give  themselves  pain,  or  even  mutilate 
themselves.  They  will  try  to  gouge  their  eyes  out 
with  their  fingers,  to  tear  the  cheek  with  the  finger  in 
the  mouth,  to  tear  out  the  testes  or  to  cut  off  the  penis. 
Prevented  from  tying  a  ligature  round  the  neck,  they 
will  endeavour  to  tie  it  round  the  leg  or  the  penis. 
Prevented  from  knocking  their  heads  against  the  wall 
they  will  take  the  skin  off  their  knuckles  by  the  same 
means,  and  so  on. 

(d)  Stubborn 

A  fourth  type  is  the  silent,  obstinate,  resistive. 
Patients  of  this  type  do  not  speak.  When  spoken  to 
they  do  not  answer.  They  make  for  the  door,  the 
window,  or  the  fire,  and  when  restrained  will  continue 
for  hours  the  same  silent,  dogged,  determined  effort 
to  reach  the  desired  destination.  They,  too,  undress 
themselves,  but  they  do  so,  not,  as  the  acute  maniac 
does,  from  the  mere  exuberance  of  their  activity,  which 
must  find  some  vent,  it  matters  not  what,  which,  when 
restrained  from  taking  off  the  coat,  begins  to  unbutton 
the  waistcoat  or  trousers.  A  patient  of  this  type 
undresses  himself  with  the  same  blind,  dogged  obstinacy 
that  he  does  everything  else.  He  persistently,  again 
and  again  for  hours  together,  attacks  the  same  button, 
or  tries  to  remove  the  same  garment  in  the  same  way. 
He,  too,  refuses  food,  but  he  refuses  it,  not,  so  far  as 
can  be  judged,  with  suicidal  intent,  but  with  the  same 
resistiveness  with  which  he  stubbornly  opposes  every- 
thing that  is  done  for  him — refuses  to  be  dressed  and 
to  be  undressed,  to  be  sat  down  or  stood  up,  to  go  to 
the  closet  and  to  come  away  from  it,  to  walk  about  or 
to  stand  still. 


190  A  TEXT-BOOK  OF  INSANITY 

(e)  Sexual 

A  fifth  type  of  acute  insanity  is  the  sexual.  A 
sexual  proclivity  is  usually  perceptible,  as  is  the 
suicidal  proclivity,  in  every  case  of  acute  insanity  ;  but, 
in  the  one  matter  as  in  the  other,  there  are  cases  in 
which  the  proclivity  becomes  so  pronounced,  assumes 
such  dominance,  is  by  so  much  the  most  prominent 
and  conspicuous  feature,  as  to  constitute  a  distinct 
type  of  the  malady.  The  sexual  type  is  exhibited 
by  women  almost  exclusively.  Few  things  are  more 
surprising  in  insanity  than  the  obscenity  and  filth  that 
are  uttered  by  women,  and  even  by  young  girls,  well 
bred  and  carefully  brought  up,  of  pure  lives,  and 
previously  innocent  conversation  and  behaviour.  They 
curse  and  swear  like  troopers  ;  they  use  expressions 
of  obscenity  and  blasphemy  of  which  a  costermonger 
would  be  ashamed.  Nor  is  it  only  in  their  speech  that 
they  display  lewdness  and  indecency.  Insane  women 
of  this  type  make  shameless  overtures  to  every  man  to 
whom  they  have  access.  Not  the  gardener  nor  the 
footman  ;  not  the  waiter  in  the  hotel  in  which  they 
are  taken  ill ;  not  the  medical  man  who  attends  them  ; 
not  even  their  own  brothers  or  fathers,  are  exempt 
from  their  libidinous  advances.  They  ogle  and  leer, 
they  throw  themselves  into  unseemly  and  indecent 
attitudes,  they  expose  their  breasts  and  legs,  and,  when 
all  this  is  ineffectual,  they  do  not  hesitate  to  ask  in 
plain  terms  for  what  they  want — to  call  out  of  the 
window  to  a  passer-by  to  come  to  bed  with  them,  or 
even,  in  plain  Saxon,  to  have  intercourse  with  them. 
As  the  melancholic  and  suicidal  varieties  of  acute 
insanity  are  often  called  acute  melancholia,  so  the 
sexual  type  is  often  called  nymphomania  ;   but  all  are 


ACUTE  INSANITY— STUPOR  191 

really  varieties  of  the  same  malady,  in  which  the 
one  or  the  other  feature,  common  to  all,  becomes 
exaggerated  and  assumes  unusual  preponderance. 

(/)  Stuporose 

This  is  as  nearly  a  distinct  and  separate  form,  as 
well  as  variety,  of  insanity  as  there  is.  In  pronounced 
cases  it  is  quite  unmistakable,  but  it  is  not  always 
pronounced,  and  an  element  of  stupor  may  often  be 
distinguished  in  cases  of  dementia  that  would  not 
be  called  stuporous,  and  especially  in  the  young,  for 
stupor  occurs  usually,  though  not  exclusively,  in  early 
life.  It  exhibits  the  signs  of  exhaustion  of  nervous 
energy,  as  though  the  highest  regions  of  the  brain 
had  been  emptied  of  motion  and  had  ceased  to  act ; 
and  it  is  usually  preceded  by  experiences  which  are 
calculated  to  drain  these  regions  of  their  energy,  and 
especially  by  a  combination  of  several  such  drains.  If 
we  wished  to  produce  a  case  of  stupor,  we  should  take 
a  young  man  between  the  ages  of  eighteen  and  twenty- 
five,  subject  him  to  severe  and  exhausting  bodily 
fatigue,  let  him  at  the  same  time  work  hard  in  pre- 
paring for  an  examination,  let  him  work  too  many 
hours  a  day,  and  have  insuflB.cient  food,  and  especially 
insufficient  sleep  ;  and  above  all,  let  him  masturbate 
freely,  and  at  the  end  of  a  month  or  two  he  will  become 
insane,  and  his  insanity  will  take  the  form  of  stupor. 
If  he  is  so  exceptionally  strong  that  these  measures  fail 
to  break  him  down,  the  last  efiort  of  resistance  can  be 
overcome  by  subjecting  him  to  some  severe  shock. 
Let  him  be  involved  in  a  railway  or  other  accident,  or 
let  him  even  witness  one,  or  let  him  come  suddenly  upon 
a  dead  body,  or  see  his  schoolfellow  dragged  drowned 


192  A  TEXT-BOOK  OF  INSANITY 

out  of  a  river,  or  let  him  be  assaulted  and  robbed,  or 
set  his  house  on  fire  in  the  night.  By  such  means  may 
stupor  be  produced  even  in  a  strong  nature ;  and  a 
weak  nature  will  not  require  such  an  aggregation  of 
causes.  Any  one  of  them  will  suffice  sometimes,  any 
two  of  them  or  three  of  them  will  usually  suffice,  especi- 
ally if  excessive  masturbation  be  among  them,  though 
this  last  factor  is  by  no  means  essential  to  the  causation 
of  stupor. 

Whatever  the  causation,  the  insanity  may  be 
stuporose  from  the  outset ;  but  more  usually  to  the 
exhausting  conditions  that  have  been  mentioned  the 
further  exhaustion  of  a  few  days  of  acute  insanity  is 
added,  and  then  the  stupor  comes  on.  The  charac- 
teristic of  the  stuporose  patient  is  his  stillness.  He 
stands  with  drooping  head  and  hanging  arms,  with 
open  mouth  and  staring  lack-lustre  eyes,  with  a  face 
void  of  expression,  in  an  attitude  void  of  vigour,  and 
thus  he  stands  all  day.  Speak  to  him,  shout  at  him, 
fire  a  pistol  behind  him,  flick  your  fingers  within  an 
inch  of  his  eyes,  you  evoke  no  response  ;  he  exhibits 
no  reaction.  Saliva  hangs  in  long  ropes  from  his  open 
mouth,  his  face  is  sweaty  and  greasy,  his  pupils  large, 
his  tongue  flabby,  his  hands  blue,  his  pulse  feeble.  Of 
food  placed  before  him  he  takes  no  notice,  but  if  it  is 
put  into  his  mouth  he  will  chew  and  swallow  it.  Yet, 
stupid  as  he  is,  and  destitute  of  most  ordinary  reactions, 
except  in  the  most  extreme  cases  he  does  not  let  his 
urine  dribble,  nor  does  he  allow  his  bowels  to  act  inap- 
propriately. He  retains  both  urine  and  fseces  until 
he  is  taken  to  the  closet,  and  when  he  is  there  he  passes 
them.  As  he  passes  his  days  in  a  state  closely  allied  to 
profound  slumber,  so  he  sleeps  well  at  night. 

Such  is  the  appearance  and  such  are  the  habits  of 


STUPOR  193 

a  well-marked  case  of  stupor.     But  the  condition  is 
not  always  as  well  marked  as  this,  and  indeed  the 
degrees  of  stupor  are  very  various.     In  milder  cases 
the  patient  moves  from  place  to  place  of  his  own 
accord,  though  his  movements  are  seldom  and  slug- 
gish.     He    may    answer    when    addressed,    but    the 
answer  is  long  in  coming,  is  brief,  and  is  uttered  in 
a  faint,  monotonous  voice.     He  may  keep  his  mouth 
shut,  exhibit  palpebral  reaction,  and  even  look  about 
him  from  time  to  time  ;    in  short,  he  may  exhibit  a 
less  degree  of  the  same  condition  ;    or,  in  rare  cases, 
the   symptoms   are   not   less,   but   more   pronounced. 
The  patient  does  not  stand,   does  not  move  under 
any  provocation.     He  lies  like  a  log ;    he  passes  his 
motions  and  urine  beneath  him.     He  does  not  even 
chew  his  food.     His  extremities  are  not  only  blue, 
but  deathly  cold,  and  the  circulation  in  them  is  so 
defective   that    sometimes   sloughs    form.     His    only 
spontaneous  movements  are  breathing  and  swallowing. 
While   spontaneous   movement  is   absent   or  mini- 
mised, the  reaction  to  "  passive  "  or  imposed  move- 
ment presents  three  well-marked  variations.     In  the 
first  class,  every  attempt  to  move  the  hmbs  or  the 
body  is  met  with  obstinate  and  intense  resistance, 
which  is  the  same  to  every  variety  of  movement  and 
in  every  part  of  the  body.    It  is  as  pronounced  in  the 
jaw  as  in  the  arm  or  leg  ;   it  is  as  obstinately  opposed 
to  flexion  as  to  extension.     It  is  as  difl&cult  to  make 
such  patients  change  their  attitude  from  standing  to 
sitting  as  to  make  them  change  from  sitting  to  stand- 
ing.    The  same  resistance  that  is  opposed  to  every- 
thing else  is  opposed  to  the  administration  of  food ; 
and  of  course  this  is  a  serious  matter,  and  influences 
the  prognosis,  which  is  worse  than  in  the  other  forms, 

0 


194  A  TEXT-BOOK  OF  INSANITY 

tkough  not  necessarily  hopeless.  This  obstinate  resist- 
ance to  imposed  movement,  when  present  in  stupor,  is 
always  associated  with  melancholic  delusion ;  it  is 
present  in  many  cases  of  acute  insanity,  and  then  also 
is  usually  associated  with  melancholy. 

The  second  and  most  frequent  variation  in  the 
reaction  to  imposed  movement  in  stupor  is  the  "  cata- 
leptic "  condition,  in  which  there  is  no  resistance  to 
the  imposition  of  movement,  and  in  which  any  atti- 
tude that  we  choose  to  impose  upon  the  patient  is 
retained  by  him.  When  the  stuporose  condition  is  not 
very  pronounced,  the  attitude  is  maintained  for  but  a 
short  time,  it  may  be  only  a  moment  or  two ;  but 
when  the  stupor  is  deep,  the  attitude  will  be  main- 
tained for  long.  We  raise  the  patient's  arm  over  his 
head,  and  there  it  will  remain  for  several  minutes. 
Dr.  Clouston  relates  a  case  in  which  a  stuporose  patient 
was  got  out  of  bed,  the  chamber-pot  was  put  into  his 
hands,  so  that  he  held  it  under  his  penis,  and  then  the 
attendant  went  away  and  forgot  him.  He  remained 
in  this  attitude  for  several  hours.  In  stuporose  cases, 
in  which  this  cataleptic  condition  exists,  the  prognosis 
is  usually  favourable. 

The  third  variation  is  that  in  which  there  is  neither 
resistance  to,  nor  retention  of,  an  imposed  attitude,  but 
a  flaccid  facility.  The  limbs  can  be  moved  with  ease, 
and  fall  back  after  movement  into  such  positions  as 
require  the  least  exertion  to  maintain.  This  is  the 
condition  to  which  the  term  "  anergic  stupor "  has 
been  given  by  Dr.  Hayes  Newington. 

The  mental  condition  in  stupor  may  be  in  one  of 
two  extreme  conditions,  or  in  any  intermediate  state 
between  them.  In  simple  stupor,  of  exaggerated 
degree,  consciousness  is  altogether  absent ;    at  least, 


STUPOE  195 

we  can  get  no  manifestation  of  consciousness  while 
the  state  continues,  and  when  it  is  past,  no  memory 
whatever  remains  of  the  experiences  of  the  stuporose 
state.  In  the  minor  degrees,  consciousness  is  pro- 
portionately diminished.  Some  sign  of  consciousness 
can  be  elicited,  some  slight  reaction  can  be  obtained ; 
after  a  question  has  been  many  times  repeated,  some 
answer  will  be  given ;  after  an  order  has  been  many 
times  insisted  on,  some  attempt  will  be  made  to  carry 
it  out ;  and  when  recovery  takes  place,  some  glimmer 
of  remembrance  will  be  retained  of  what  occurred 
during  the  illness. 

The  other  form  of  stupor  is  called  melancholia  cum 
stupore,  or  melancholia  attonita,  or  melancholy  stupor, 
since  in  it  there  is  always  misery,  and  sometimes  the 
depression  is  profound.  The  depression  is  somewhat 
difierent  from  that  of  ordinary  melancholia,  and  is 
more  of  the  nature  of  panic  or  horror.  The  sense  of 
personal  unworthiness  and  incapacity  which  accompanies 
dysphoria  is,  indeed,  present,  but  in  addition  to  this 
is  an  overwhelming  horror  at  something  that  the 
patient  deludedly  believes  to  have  occurred,  or  to  be 
about  to  occur.  Unlike  the  previous  form  of  stupor, 
consciousness  is  not  only  present,  but  seems,  as  it  were, 
to  be  intensified.  The  patient  is  keenly  alive  to  every- 
thing that  is  going  on  around  him,  but  everything  that 
happens  is  woven  into  his  dream,  and  goes  to  corroborate 
and  intensify  it.  If  he  is  compelled,  for  instance,  to 
take  food,  to  dress  or  to  undress,  to  sit  down  or  to  walk, 
this  interference  is  interpreted  by  him  to  be  the  actual 
beginning  of  that  terrible  torture  to  which  he  is  to  be 
submitted,  and  the  attendants  who  so  interfere  with 
him  are  his  executioners.  Hence  his  stubborn  resist- 
ance. 


196  A  TEXT-BOOK  OF  INSANITY 

The  treatment  of  stupor  may  be  summed  up  in  two 
words — feeding  and  rest.  The  state  is  one  of  exhaus- 
tion, and  the  treatment  must  be  directed  to  restore 
the  exhausted  energy.  To  this  end  feeding  must  be 
copious.  Such  patients  must  have  much  more  than 
the  ordinary  full  diet  which  would  suffice  for  a  healthy 
person  of  the  same  age,  and,  in  young  people  at  any 
rate,  it  should  be  highly  nitrogenised — plenty  of  eggs 
and  plenty  of  meat,  with  a  moderate  quantity  of 
alcohol.  When  solid  food  cannot  be  administered, 
of  course  slops  must  be  given,  but  essences  and  extracts 
are  useless.  Milk  is  always  valuable,  and  when  food 
cannot  be  given  in  solid  form,  it  should  be  given,  not 
as  liquid,  but  as  thin  porridge,  that  is  to  say,  mth 
plenty  of  finely  divided  solids  suspended  in  it.  Bread 
sauce  is  an  excellent  food,  and  may  be  mixed  with 
pounded  meat. 

Rest  is  the  complement  of  feeding.  Since  energy 
is  exhausted,  every  demand  upon  energy  must  be 
minimised,  and  therefore  the  patient  should  be  kept 
warm,  and  usually  he  should  be  kept  in  bed.  He  must 
be  vigilantly  watched  to  prevent  masturbation,  which 
often  goes  on  in  a  quasi- automatic  manner  ;  and  sleep, 
the  great  restorer  of  exhausted  energy,  should  be  en- 
couraged, and  if  necessary  induced  by  hypnotics. 

The  same  indications  govern  our  administration  of 
drugs.  Cod-liver  oil,  Easton's  syrup,  and  other  pre- 
parations of  iron,  quinine,  strychnine,  and  phosphorus 
all  appear  to  assist  recovery.  Baths  and  friction  are 
useful,  but  massage  is  not  advisable. 

In  simple  stupor,  the  prognosis  is  usually  favourable. 
It  occurs  commonly  in  young  people,  in  whom  recupera- 
tive power  is  active,  digestion  good,  and  sleep  easily 
induced  ;   and,  moreover,  in  this  form  there  is  neither 


STUPOR  197 

refusal  of  food  nor  exhaustion  from  struggling  during 
its  administration.  In  melancholy  stupor  the  prospect 
is  much  less  favourable.  It  may  occur  at  any  age ; 
sleep  is  usually  difficult  to  induce,  and  the  strenuous 
resistance  to  feeding  and  other  necessary  offices  keeps 
a  perpetual  drain  upon  the  strength.  Hence  recovery 
is  in  this  form  less  frequent,  it  is  longer  delayed,  and  a 
much  larger  proportion  of  the  cases  end  either  in  death 
or  in  permanent  insanity. 

In  other  characters,  as  well  as  in  those  mentioned, 
melancholic  stupor  shades  off  by  insensible  degrees 
into  other  forms  of  acute  insanity,  and  many  cases 
which  would  usually  be  classed  as  melancholy  insanity 
exhibit  the  panic  and  horror  that  are  so  prominent  in 
this  form  of  stupor.  When,  as  not  seldom  happens,  the 
subject  of  melancholic  stupor  exhibits  sudden  out- 
breaks of  impulsive  violence,  directed  either  against 
himself  Or  against  others,  or  similarly  impulsive  out- 
breaks of  destructiveness,  the  case  approaches  in 
character  to  ordinary  acute  insanity ;  and  the  affinity 
of  the  two  forms  of  insanity  is  further  exhibited  in  the 
occasional  transition  of  the  one  into  the  other.  The 
stuporose  patient  loses  his  apathy,  his  outbreaks  of 
excitement  become  more  frequent,  and  he  passes,  on 
his  way  to  chronic  quiet  dementia,  through  a  period  of 
acute  maniacal  insanity. 

Whatever  the  type  of  the  acute  insanity,  there  are 
certain  features  common  to  them  all.  All,  as  we  have 
seen,  are  potential  suicides.  In  all  there  is  at  one  time 
or  another  refusal  of  food,  alternating,  it  may  be,  with 
wolfish  voracity.  In  all  there  are  sexual  proclivities, 
showing  themselves  in  frequent  shameless  mastur- 
bation, as  well  as  in  other  ways.  In  all  there  is  in- 
attention,  not  only  to  ordinary  tidiness  and  clean- 


198  A  TEXT-BOOK  OF  INSANITY 

liness,  but  to  the  calls  of  nature.  They  pass  their 
urine  and  motions  under  them,  either  occasionally  or 
habitually,  according  to  the  gravity  of  the  case.  Their 
clothes  soon  become  ragged,  dirty,  stained,  and  caked 
with  spilt  food.  In  all  cases  of  acute  insanity,  sleep- 
lessness is  a  very  prominent  and  very  important 
symptom.  It  has  usually  existed  for  days  or  weeks 
before  the  insanity  declares  itself,  and  it  is  aggravated 
when  this  takes  place.  The  length  of  time  for  which 
they  will  maintain  their  excessive  activity  without 
sleep,  or  with  only  an  hour  or  two  of  sleep  per  night, 
is  astonishing.  They  are  always  constipated,  and  the 
tongue  is  usually  foul,  and  the  breath  stinking.  They 
have  usually  lost  a  great  deal  of  weight  before  the 
insanity  declares  itself.  When  they  are  sufficiently 
rational  to  give  an  account  of  themselves,  they  are 
found  to  be  suffering  from  delusions.  In  the  melan- 
choly type  these  are  the  ordinary  delusions  of  melan- 
cholia, sometimes  combined  with  delusions  of  perse- 
cutory type.  In  the  excited  or  maniacal  type  the 
delusions  are  of  a  very  extravagant  character.  The 
patient  has  visited  heaven  and  made  the  personal 
acquaintance  of  the  Almighty,  or  he  has  attended  his 
own  funeral,  or  he  has  some  other  equally  extravagant 
belief.  Hallucinations  are  rarely  prominent,  and  often 
not  present  in  acute  insanity,  and  when  present  are 
usually  visual.  It  is  rare  for  patients  with  acute  in- 
sanity to  "  hear  voices,"  and  those  who  do  are  usually 
of  the  resistive  type. 

Acute  insanity  is  very  variable  in  course  and  duration. 
In  a  few  cases  it  is  very  evanescent,  and  clears  up 
completely  and  permanently  in  twenty-four  or  forty- 
eight  hours  ;  and  such  cases  constitute  what  has  been 
called    mania    transitoria.      Usually  it   lasts   in    full 


ACUTE  INSANITY— TREATMENT        199 

intensity  for  from  one  to  four  or  five  weeks,  and  if  the 
longer  term  is  reached,  it  then  terminates  fatally  from 
exhaustion.  The  earlier  improvement  begins,  the  more 
favourable  the  chance  of  recovery  ;  the  longer  the  full 
intensity  of  the  malady  lasts,  the  graver  the  prognosis. 
Four  or  five  weeks  of  really  acute  mania  will  kill  the 
strongest  man,  and  a  shorter  term,  even  if  not  fatal 
to  life,  is  very  apt  to  leave  irreparable  damage  to  the 
brain  and  mind.  Of  the  five  types  described,  the 
resistive  is  the  most  unfavourable  to  life,  and  the 
suicidal  is  the  most  apt  to  leave  permanent  insanity. 
When  recovery  takes  place,  it  often  takes  place 
suddenly.  The  patient  has  a  night  of  long,  sound 
sleep,  and  wakes  up  well,  or  so  nearly  well  that  a  few 
days  completes  the  recovery  ;  but  this  can  only  happen 
when  the  malady  has  been  of  sudden  onset  and  short 
duration.  In  other  cases,  improvement  is  gradual,  the 
excitement  subsides,  the  melancholy  clears  away,  and 
the  patient  passes  into  a  state  of  slight,  or  it  may 
be  of  grave,  dementia,  from  which  he  may  gradually 
emerge,  or  which  may  remain  permanent  for  the  rest 
of  a  long  life.  In  other  cases  the  subsidence  of  the 
excitement  is  simultaneous  with  fixation  and  systema- 
tisation  of  the  delusions,  and  the  acute  insanity  merges 
without  break  into  paranoia.  Even  when  recovery  is 
rapid  and  appears  complete,  the  patient  should  not 
return  to  the  active  duties  of  life  for  at  least  a  third 
or  half  a  year,  and  he  will  always  be  liable,  on  a  recur- 
rence of  the  conditions,  to  a  recurrence  of  the  malady. 

The  effective  treatment  of  acute  insanity  may 
be  summed  up  in  two  words — food  and  sleep.  In 
the  rare  cases  in  which  a  patient  has  been  eating 
and  sleeping  fairly  well  up  to  the  time  of  the  outbreak 
of  insanity,  the  prognosis  is  extremely  unfavoui-able ; 


200  A  TEXT-BOOK  OF  INSANITY 

and  the  more  confidently  we  can  attribute  the  outbreak 
to  deficiency  of  food  and  sleep,  the  more  confidently 
may  we  expect  that  the  administration  of  food  and 
the  procurement  of  sleep  will  be  followed  by  recovery. 
As  the  sleeplessness  depends  very  largely  upon  the 
inanition,  our  first  care  must  be  to  administer  abund- 
ance of  food.  The  patient  must  not  merely  be  fed, 
he  must  be  over-fed.  He  must  have  food  in  super- 
abundance and  excess ;  he  must  have  twice  or  three 
times  as  much  as  would  sufiice  for  a  healthy  man  of  his 
age  and  weight.  What  he  needs  is  not  extract  of  meat 
and  Brand's  essence,  and  Bovril  and  Valentine's  meat 
juice,  and  similar  concentrates,  but  bulky,  ordinary 
food — meat  and  potatoes,  bread  and  butter,  rice 
pudding,  and  such  like  viands  in  great  quantity. 
And  here  we  are  met  at  the  outset  by  two  serious 
difficulties — ^first,  that  digestion  is  very  frequently 
disordered,  and,  second,  that  the  food  is  very  frequently 
refused. 

The  first  difficulty  we  may  often  disregard.  The 
stomach  has  perhaps  been  pampered  and  humoured  for 
months  by  discarding  first  one  food  and  then  another 
that  has  been  thought  to  disagree  with  it,  and  if  it  is 
taken  firmly  in  hand  and  compelled  to  receive  all 
kinds  of  bland  food,  it  will  do  its  duty  uncomplain- 
ingly. A  more  serious  matter  is  that  when  food  has 
for  months  been  taken  in  small  quantity  only,  the 
stomach  has  become  contracted,  and  till  it  has  been 
educated  to  receive  larger  quantities,  it  will  resent 
over- distension  by  vomiting.  In  such  cases  we  must 
be  content  to  feed  very  frequently,  and  gradually  to 
increase  the  amount  given  at  each  meal. 

The  other  difficulty  is  far  more  serious.  Refusal  of 
food,  obstinate  resistance  to  the  administration  of  food, 


ACUTE  INSANITY— TREATMENT        201 

is  a  common  feature  of  all  the  types  of  acute  insanity, 
and  unless  it  is  overcome,  the  patient  will  certainly  die. 
It  must  therefore  be  dealt  with  promptly  and  vigor- 
ously. The  patient  must  be  forcibly  fed.  There  are 
degrees  of  persistence  of  refusal.  Some  patients  will 
not  feed  themselves,  but  if  the  food  is  put  to  the 
mouth,  they  will  take  it  with  docility,  chew  and 
swallow  it.  Others  will  take  it  only  if  spoon-fed ; 
the  rest — and  these  are  the  majority — will  refuse  and 
resist  every  attempt  to  feed  them.  Various  methods 
of  forcible  feeding  are  in  use  for  such  cases,  but  I 
have  no  hesitation  in  condemning  all  but  one.  The 
nasal  tube,  a  small  tube  of  soft  rubber  introduced  into 
the  nostril,  has  been  used  very  largely,  but  it  is  so 
easy  for  a  suicidal  patient,  or  even  a  greatly  demented 
patient,  to  inhale  the  food  thus  administered ;  and  so 
many  cases  of  gangrene  of  the  lung  have  followed  the 
use  of  the  method  ;  that  it  ought  to  be  abandoned,  and 
the  oesophageal  tube  used  in  every  case. 

Of  course,  in  this  case,  solid  food  cannot  be  given 
in  solid  form ;  but  the  same  food  can  be  given  if  it  is 
first  pounded  up  in  a  mortar  and  made  into  a  thin 
pulp  with  milk,  and  then  there  is  the  advantage 
that  the  appetite  and  palate  need  not  be  consulted, 
and  food,  stimulants,  and  drugs  can  be  administered 
together.  If  a  really  copious  and  excessive  amount  of 
food  is  introduced,  the  dijB&culty  about  sleep  is  already 
half  overcome  ;  but  there  are  few  cases,  though  there 
are  a  few,  in  which  food  alone  is  sufficient  to  procure 
sleep.  In  most  cases  hypnotic  drugs  have  to  be  em- 
ployed. Our  choice  of  these  has  greatly  extended  o£ 
late  years.  There  was  a  time  when  opium  was  the 
only  soporific  ;  then  chloral  and  bromide  of  potassium 
were  added ;    now  all  these  are  abandoned  in  the 


202  A  TEXT-BOOK  OF  INSANITY 

treatment  of  acute  insanity,  and  newly  discovered 
drugs  are  found  to  be  more  efficacious  and  attended 
by  fewer  disadvantages. 

The  question  often  arises,  what  is  to  be  done  upon 
the  instant  to  control  a  patient  who  has  suddenly 
become  acutely  insane  in  his  own  house,  or  in  an  hotel, 
or  elsewhere  ;  who  is  tearing  up  his  clothes  and  smash- 
ing the  furniture,  who  has  worn  out  his  friends  and 
the  ex-policeman  who  has  been  called  in  to  help  in 
controlling  him  ?  In  this  state  of  things  we  have  in 
hyoscin  an  agent  of  the  utmost  value.  It  is  made  up 
for  hypodermic  use  in  minute  tabloids,  and  one  of  these 
can  be  dissolved  in  a  cup  of  tea  or  a  glass  of  wine,  or, 
if  needs  must,  it  can  be  given  hypodermically,  and  its 
action  is  very  speedy  and  very  effectual.  The  usual 
doses — -^ho  and  -^t  oi  a,  grain — are  of  no  use  in  acute 
insanity,  and  at  least  -^  should  be  given  under  the 
skin,  or  -srV  by  the  mouth.  I  give  -^  hypodermically, 
and  have  never  seen  any  ill-effects  from  its  use.  Ill- 
effects,  and  fatal  effects,  used  sometimes  to  attend  its 
use  when  the  drug  was  first  introduced,  but  no  case 
has  been  reported  of  late  years,  and  I  cannot  help 
thinking  that  when  it  has  been  fatal,  either  the  drug 
was  impure,  or  it  was  insufficient^  mixed,  and  larger 
doses  were  given  than  were  intended.  At  any  rate, 
if  there  is  any  risk  attached  to  its  use  now,  it  is  a  risk 
that  ought  to  be  run,  for  the  danger  of  the  drug  is  in 
any  case  not  so  great  as  the  danger  of  allowing  the 
patient  to  die  of  exhaustion  ;  and  therefore  it  should  be 
given.  In  this  way  a  breathing-time  may  be  obtained, 
during  which  the  friends  are  freed  from  the  absorbing 
task  of  immediate  attendance  on  the  patient,  and  are 
at  liberty  to  take  the  necessary  steps  to  have  him 
removed  to  an  institution.    For  this  course  is  essential 


ACUTE  INSANITY— DRUGS  203 

in  every  case  of  acute  insanity,  except,  perhaps,  wKen 
the  patient's  friends  are  very  wealthy,  and  can  arrange 
for  at  least  three  attendants  and  a  medical  man  to 
reside  in  the  house  with  him,  and  even  then  the  con- 
ditions for  his  control  and  recovery  are  not  so  favour- 
able as  they  would  be  in  any  well-conducted  institution. 
It  is  scarcely  justifiable  to  keep  up  a  full  administration 
of  hypnotics  merely  for  the  purpose  of  facilitating  the 
control  of  a  patient,  and  unless  this  is  done,  there  will 
be  times  when  two,  and  even  three,  attendants  will  be 
insufficient  to  control  an  acute  maniac.  He  should  be 
in  a  place  where  practically  unlimited  help  can  be 
brought  to  bear  to  get  him  undressed,  or  dressed,  or 
fed,  as  the  case  may  be.  There  is  nothing  so  likely  to 
produce  bodily  injuries  as  insufficiency  of  help  in  these 
operations. 

There  is  a  practical  measure  of  great  value,  which  is 
much  insisted  upon  by  Dr.  Savage  in  the  management 
of  acute  insanity  so  long  as  the  patient  is  kept  at 
home,  and  this  is  to  remove  the  patient  at  once  to  the 
ground  floor,  bag  and  baggage,  bed  and  bedding. 
Then  if  he  jumps  out  of  the  window  he  can  do  himself 
but  little  harm. 

Useful  as  hyoscin  is  as  a  calmative  and  controller  of 
excitement  upon  emergency,  it  is  not  a  drug  to  be  used 
as  an  hypnotic,  nor  is  it  suitable  for  prolonged  adminis- 
tration, for  tolerance  is  soon  established,  and  the  dose, 
to  be  effectual,  has  to  be  increased.  When  we  desire 
an  hypnotic  effect,  the  most  efficient  drug  for  ordinary 
use  in  acute  insanity  is  sulphonal,  a  drug  that  has  the 
great  advantage  that  it  not  only  induces  sleep  at  night, 
but  has  a  calmative  influence  upon  the  patient  for  the 
following  day.  Its  disadvantages  are  various.  In  the 
first  place,  its  action  is  delayed,  and  it  varies  much  in 


204  A  TEXT-BOOK  OF  INSANITY 

the  period  after  administration  at  which  its  effects 
begin  to  be  felt.  Sometimes  it  will  act  in  an  hour, 
sometimes  not  for  two,  three,  six,  or  as  much  as  twelve 
hours.  It  is  therefore  manifestly  inappropriate  when 
we  desire  an  immediate  effect.  Trional,  upon  the 
other  hand,  is  a  drug  whose  action  is  far  more  speedy, 
almost  as  effectual,  and  much  less  lasting.  It  has  none 
of  the  delayed  calmative  effect  that  is  so  characteristic 
of,  and  important  in,  sulphonal.  The  best  effect  of 
both  drugs  is  obtained  by  a  combination  of  the  two. 
A  combination  of  about  |  trional  with  f  sulphonal  is 
most  valuable.  The  trional  puts  the  patient  to  sleep, 
and  the  sulphonal  keeps  him  asleep — ten  grains  of  one 
to  fifteen  grains  of  the  other,  or  better,  fifteen  grains  of 
the  one  to  twenty-five  of  the  other.  If  this  is  given 
the  first  night,  a  less  dose  will  suffice  for  the  second,  a 
still  smaller  for  the  third,  and  on  the  fourth  night  the 
patient  will  usually  sleep  without  drugs.  The  same 
hypnotic  should  not  be  given  for  long  together.  They 
are  much  more  effectual  when  changes  are  rung  upon 
them.  In  the  melancholic  form  of  acute  insanity,  and 
when  there  is  cardiac  weakness,  paraldehyde  is  a  very 
valuable  hypnotic. 

Mention  has  already  been  made  of  the  disorder  of 
digestion  that  is  so  frequent  in  acute  insanity.  In  any 
case  in  which  it  is  ascertainably  present,  it  must  be 
treated.  There  are  cases  in  which  the  contents  of  the 
stomach  undergo  putrefactive  or  fermentative  changes 
which  render  them  unspeakably  foul  and  offensive,  and 
when  this  is  the  case,  or  whenever  the  breath  is  very 
foul,  or  especially  when  foul  gases  are  expressed  from 
the  oesophageal  tube  when  the  end  reaches  the  stomach, 
benefit  will  be  derived  from  washing  out  the  stomach 
at  regular  intervals. 


CHRONIC  INSANITY  205 

In  all  cases  of  acute  insanity,  certainly  in  all  which 
are  severe  or  prolonged,  institution  treatment  is  essen- 
tial. In  many  cases  it  is  far  better  for  the  patient 
to  have  the  comparative  freedom  of  a  padded  room 
than  to  be  perpetually  checked  and  interfered  with  by 
attendants. 

The  first  favourable  symptoms  are  the  establishment 
of  natural  sleep,  the  voluntary  taking  of  food,  sub- 
sidence of  excitement,  and  commencing  appreciation 
by  the  patient  of  his  circumstances.  If  all  these  are 
concurrent  with  a  gain  of  weight,  and  occur  within  the 
first  fortnight,  there  is  reasonable  hope  of  complete 
recovery.  But  if  sleep  is  established,  food  taken,  and 
weight  gained,  while  still  the  mind  does  not  improve, 
the  prognosis,  while  improved  as  to  life,  is  very  gloomy 
as  to  recovery  of  reason ;  and  if  improvement  is 
delayed  beyond  the  first  fortnight,  every  day's  delay  is 
of  consequence. 


CHRONIC  INSANITY 

By  chronic  insanity  is  meant  here  insanity  that  is 
either  not  of  recent  origin  or  that,  if  of  recent  origin,  is 
not  intense.  It  is,  of  course,  true  that  chronic  means  in 
the  literal  sense  of  long  duration,  but  in  the  first  place 
there  is  no  one  word  which  connotes  the  alternative  of 
long  duration  or  lack  of  intensity,  and  in  the  second,  the 
term  chronic  insanity  has  never  been  appropriated  to 
any  particular  class,  and  in  bringing  it  for  the  first 
time  into  use  I  imagine  I  am  at  liberty  to  give  it  any 
signification  I  please.  I  therefore  consider  that  the 
definition  I  have  given  is  quite  justifiable. 

Thus  defined,  chronic  insanity  may  be  divided  into 
two  important  classes  or  sub- types,  and  a  rabble  of 


206  A  TEXT-BOOK  OF  INSANITY 

others  which  need  not  be  considered  here.  The  two 
sub-types  that  stand  out  with  clear  characterisation  are 
fixed  delusion  and  dementia.  The  sub-type  fixed 
delusion  happens  to  coincide  with  the  kind  of  insanity 
similarly  entitled,  and  is  more  conveniently  described 
among  the  kinds,  where  it  will  be  found.  The  other 
clear  sub-type,  dementia,  is  also  well  characterised,  and 
as  it  does  not  coincide  with  any  kind,  but  like  the  type 
acute  insanity  is  witnessed  in  several  kinds  of  insanity, 
it  falls  to  be  described  here. 


DEMENTIA 

Dementia  is  that  type  of  chronic  insanity  in  which 
there  is  no  such  outstanding  predominant  feature  as 
fixed  delusion  or  a  cyclical  course,  but  the  insanity  is  a 
general  degradation  affecting  in  various  degree,  and  to 
various  depths  in  the  different  cases,  all  the  faculties 
of  mind.  Although  it  is  a  general  defect,  it  is  not  neces- 
sarily a  simple  defect.  It  is  complicated  in  most  cases 
with  over-action  on  the  lower  levels  that  the  defect  has 
not  yet  reached,  as  has  been  explained  in  the  description 
of  anoia.  Anoia  is  a  form  of  insanity,  that  is  to  say,  a 
group  of  symptoms  made  up  of  disorder  of  conduct  and 
mind,  that  may  be  present  in  any  kind  of  insanity — in 
any  of  the  different  diseases  of  which  insanity  consists — 
and  that  is  in  fact  present  in  some  degree  in  every  such 
disease.  Dementia  is  that  particular  kind  or  disease  of 
insanity  in  which  the  symptoms  are  those  of  anoia  only, 
and  in  which  no  single  accompaniment  of  anoia — no 
delusion,  no  excess  of  feeling,  no  excitement  in  conduct, 
— is  so  predominant  as  to  obscure  the  anoia,  which  now 
stands  out  as  the  predominant  symptom. 

But  though  anoia,  or  simple  deficiency  of  conduct  and 


CHEONIC  INSANITY— DEMENTIA        207 

mind,  is  the  predominant  symptom,  it  is  not  necessarily 
the  only  symptom.  In  many  cases  there  are  from  time 
to  time  outbreaks  of  excitement,  in  some  there  may  be 
from  time  to  time  fleeting  delusions,  in  others  there  is 
continuous  excess  of  some  low  grade  of  conduct,  as  has 
been  described  in  treating  of  anoia  ;  but  in  all  the  pre- 
dominant feature  is  the  anoia — the  defect  of  mind  and 
conduct. 

As  has  already  been  stated,  the  Scotch  school  of 
alienists  look  upon  dementia  as  an  irrecoverable  disease, 
and  would  deny  the  name  to  any  case  of  insanity, 
however  characteristic  the  symptoms  of  anoia,  if  the 
patient  were  to  recover.  I  cannot  agree  that  the  way 
in  which  a  disease  terminates  forms  a  satisfactory  basis 
for  classifying  it.  Even  the  school  of  Kraepelin, 
though  it  constitutes  the  disease  of  dementia  prsecox 
mainly  on  the  basis  of  the  irrecoverabihty,  or  as  they 
call  it  the  incurability,  of  the  disease,  yet  admit  that 
some  cases  do  recover.  The  admission  knocks  the  bottom 
out  of  their  classification  and  leaves  them  in  chaos,  but 
this  does  not  trouble  the  minds  of  those  who  think  they 
have  got  hold  of  something  new,  and  have  all  the 
enjoyment  of  playing  with  a  new  toy. 

The  indisputable  fact  is  that  though  in  a  great  many 
cases  anoia  may  be  the  expression  of  actual  structural 
deterioration  of  the  brain,  and  in  these  cases  the 
dementia  is  irrecoverable,  yet  in  some  cases  there  is 
little  or  no  structural  damage  of  the  brain,  and  a 
minority  of  the  cases,  a  lamentably  small  minority,  do 
recover.  We  do  not  yet  know  whether  the  structural 
deterioration  which  is  found  after  death  in  cases  in 
which  dementia  has  been  of  long  standing  is  the  cause 
or  structural  basis  of  the  dementia,  or  whether  it  is  not 
atrophy  resulting  from  long  disuse.     However  this  may 


208  A  TEXT-BOOK  OF  INSANITY 

be,  a  certain  number  of  cases  of  dementia  recover,  and  in 
these  cases  the  symptoms  of  the  disease,  while  it  lasted, 
are  indistinguishable  from  those  of  other  cases  that  go  on 
for  many  years  and  never  recover.  I  do  not  think  that 
the  different  termination  of  a  disease  in  recovery  or 
death  constitutes  a  sufficient  basis  for  regarding  the 
cases  that  recover  as  suffering  from  one  kind  of  disease 
and  those  that  do  not  recover  as  suffering  from  another. 
The  difference  is  not  made  a  basis  for  classification  in 
any  other  disease,  and  there  seems  no  good  reason  for 
making  it  a  basis  of  classification  in  insanity. 

Dementia  is  a  sub-type  of  disease  that  is  presented  by 
several  kinds  of  insanity.  We  see  it  in  youth,  in  middle 
age,  and  in  old  age,  and  at  each  time  of  life  it  has 
peculiarities  that  are  fairly  distinctive ;  and  when  the 
dementia  constitutes  the  whole  of  the  correlated  dis- 
orders from  which  the  patient  suffers,  it  is  properly 
considered  a  disease,  and  reappears  under  that  title 
among  the  kinds  of  insanity  hereafter  considered.  But 
there  are  cases,  advanced  general  paralysis  for  instance, 
in  which  the  dementia  constitutes  not  the  whole,  but  a 
part  only  of  the  correlated  disorders  from  which  the 
patient  suffers,  and  in  such  cases  the  dementia  is  not 
the  whole  disease.  The  disease  is  general  paralysis,  of 
which  one  symptom  or  group  of  symptoms  is  insanity 
of  chronic  type,  the  sub-type  being  dementia. 


CHAPTER   VII 


KINDS   OF  INSANITY 


The  mode  that  was  adopted  in  the  last  chapter  of 
classifying  the  disease  insanity,  the  classification  into 
acute  insanity  and  chronic  insanity,  is,  as  far  as  it  goes, 
a  useful  classification ;  but  it  does  not  go  far,  and  it  is 
not  the  only  mode  of  classification.  As  has  already 
been  pointed  out,  it  is  a  mistake  to  suppose  that  there 
is  but  one  ideally  perfect  mode  of  classifying  anything, 
and  that  all  other  modes  are  wrong.  Things  can  be 
classified  in  as  many  ways  as  they  have  difierent 
qualities  to  serve  as  a  means  of  classification,  and  in 
fact  must  or  ought  to  be  classified  in  difierent  ways  for 
difierent  purposes.  There  may  be  a  best  way  of  classify- 
ing for  each  purpose,  but  there  will  be  at  least  as  many 
ways  of  classifying  as  there  are  purposes  to  be  served  by 
the  classification.  For  clinical  purposes  the  classifica- 
tion of  insanity  into  acute  and  chronic  is  a  very  useful 
and  suitable  and  valid  classification,  but  for  the  purpose 
of  organising  our  knowledge  it  is  unsuitable  because  it 
results  in  classes  one  of  which  is  a  heterogeneous  mixture 
of  dissimilar  cases.  For  this  purpose  we  must  seek 
another  basis  of  classification.  In  most  books  on  insanity 
it  will  be  found  rather  dogmatically  stated  that  the 
only  true  and  satisfactory  classification  of  insanity 
p  209 


210  A  TEXT-BOOK  OF  INSANITY 

must  be  that  which  has  a  pathological  basis,  in  other 
words  that  in  which  the  fundamentum  divisionis  is  the 
kind  of  structural  change  in  the  brain  that  underlies  the 
symptoms  of  insanity  and  enters  into  the  constitution 
of  the  disease  of  insanity.  I  cannot  find  any  rational 
foundation  for  this  doctrine.  Even  in  bodily  diseases  it 
is  not  true  that  the  classification  is  always  founded  on 
the  structural  change  that  underlies  the  symptoms. 
Many  diseases  are  classified  by  the  agent  that  produces 
them.  Such  are  syphilis,  tuberculosis,  hydatids,  and 
many  others.  And  it  is  demonstrable  that  all  insanity 
cannot  be  classified  by  the  structural  change  in  the 
brain,  because  in  some  cases  of  insanity  there  is  no  such 
change,  as  is  shown  by  complete  recovery.  We  may 
therefore  put  aside  the  ideal  of  a  pathological  classifica- 
tion as  both  unnecessary  and  impracticable  ;  but  it  does 
not  follow  that  there  is  no  practicable  classification,  and 
some  classification  is,  as  we  have  found,  necessary.  I 
do  not  say  that  the  classification  I  am  about  to  propose 
is  the  only  practicable  classification.  What  I  have 
already  said  shows  that  it  is  not ;  but  it  is  at  any  rate 
a  valid  classification,  made  in  accordance  with  the 
accepted  canons  of  classification,  and  therefore  free  from 
cross- classification,  which  is  more  than  can  be  said  of 
any  of  its  predecessors. 

Taking  the  principle  of  Evolution  as  the  first  funda- 
mentum we  get  the  two  main  classes  already  indicated 
according  as  evolution  is  imperfect  and  has  been 
arrested  at  an  incomplete  stage,  or  according  as  evolution 
has  been  complete  and  has  subsequently  been  reversed. 
Thus  the  primary  division  is  into — 

I.  Insanity  of  undevelopment  or  Involute  Insanity. 
II.  Insanity  of  dissolution  or  Dissolute  Insanity. 


INVOLUTE  INSANITY  211 

Insanity  of  undevelopment,  in  its  various  degrees 
of  idiocy,  imbecility,  and  feeble-mindedness,  is  rationally 
divisible  into  three  kinds  according  to  the  reason  of  the 
undevelopment.    This  may  be  due  to  : 

A.  Defect  of  the  developmental  impetus  communi- 
cated by  the  sperm  cell  to  the  germ  cell  at  conception, 
so  that  the  process  of  development  comes  to  a  premature 
end  from  mere  lack  of  vigour. 

B.  Defect  of  some  chemical  product  of  metabolism, 
the  presence  of  which  is  necessary  to  normal  develop- 
ment. Undevelopment  due  to  this  cause  may  be  recog- 
nised by  the  presence  of  many  co-ordinated  or  correlated 
defects,  forming  a  recognisable  group  that  occurs  again 
and  again  in  difierent  cases.  In  one  case,  that  of 
cretinism,  the  defective  chemical  has  been  identified, 
and  is  known  to  be  the  secretion  of  the  thyroid  gland. 
In  other  cases,  e.g.  microcephaly  and  mongolian  idiocy, 
the  defective  chemical  has  not  yet  been  identified,  but 
the  presence  of  a  number  of  correlated  defects  compels 
us  to  conclusively  presume  that  the  undevelopment  is 
due  to  such  a  deficiency,  either  absolute  or  relative. 

C.  In  a  third  class  of  cases  arrest  of  development  is 
due  to  the  action  upon  the  brain  of  some  extraneous 
agent,  which  may  be  either  of  two  main  kinds  : 

1.  Mechanical  violence  applied  to  the  head,  either  in 
the  natural  passage  of  a  large  head  through  a  narrow 
passage  at  birth,  or  by  instrumental  delivery,  or  by  a 
fall  or  a  blow  in  infancy. 

2.  The  action  of  a  microbe,  or  of  the  toxin  produced 
by  a  microbe,  which  may  be  that  of  syphilis,  measles, 
scarlet  fever,  small-pox,  etc.,  and  may  act  directly  upon 
the  brain,  or  indirectly  through  inflammation  of  the 
meninges. 


212  A  TEXT-BOOK  OF  INSANITY 

DISSOLUTE  INSANITY 

In  every  case  of  insanity  we  postulate  disorder  of  the 
brain,  and  this  disorder  of  brain,  taken  together  with 
the  disorders  of  conduct,  mind,  and  metabohsm  that 
depend  on  it,  constitute  the  disease  of  insanity  in  those 
cases  in  which  insanity  exists  alone — in  which  it  includes 
the  whole  of  the  correlated  disorders  from  which  the 
patient  suffers.  But  in  many  cases  the  insanity,  thus 
understood,  does  not  include  the  whole  of  the  correlated 
disorders  from  which  the  patient  suffers.  In  many 
cases  the  disorder  of  brain  is  itself  but  a  part  of  a  more 
widespread  disorder,  affecting  also  other  organs,  or  the 
whole  of  the  body,  and  due,  it  may  be,  to  disorder  of 
some  other  organ,  such  as  the  thyroid,  or  to  the  invasion 
of  a  microbe,  as  in  the  delirium  of  specific  fever,  or  to 
some  generally  distributed  poison,  such  as  that  of  gout. 
In  these  cases,  the  form  of  insanity — the  disorder  of 
mind  and  conduct — is  a  symptom,  directly  of  brain 
disorder,  and  indirectly,  through  the  brain  disorder,  of 
the  disorder  of  the  thyroid,  or  of  the  specific  fever,  or  of 
gout.  We  must  therefore  recognise  that  the  disease 
insanity — the  threefold  disorder  of  conduct,  mind,  and 
brain — may  be  an  independent  disease  or  a  symptomatic 
disease,  according  as  it  does  or  does  not  include  all  the 
correlated  disorders  from  which  the  patient  suffers  ; 
and  the  first  division  that  we  make  of  the  insanity  of 
dissolution  is  into  symptomatic  insanity  and  idiopathic 
insanity. 

In  symptomatic  insanity,  the  prominence  and  im- 
portance of  the  insanity  varies  much  in  different  cases. 
When  delirium  occurs  in  specific  fevers,  the  bodily 
symptoms  usually  preponderate.  They  precede  the 
delirium  hj  days  or  weeks,  and  persist  after  the  delirium 


SYMPTOMATIC  INSANITY  213 

subsides ;  and  throughout  the  delirium  the  bodily 
symptoms  take  rank  of  it  in  importance  and  prominence. 
The  delirium  is  but  an  incident  in  the  course  of  the 
disease.  The  same  thing  may  occur  when  insanity 
occurs  as  a  symptom  of  gout.  But  sometimes  the 
insanity  is  for  the  time  being  more  prominent  than  the 
bodily  disease,  and  the  bodily  disease  may  even  be 
overlooked.  The  same  may  be  the  case  in  myxoedema 
and  in  other  diseases.  Sometimes  the  insanity  is  the 
more  prominent,  and  the  bodily  disease  may  escape 
notice  unless  the  observer  is  on  the  alert  to  look  out  for 
it :  in  other  cases  the  bodily  disease  preponderates,  and 
the  insanity  may  be  but  a  transient  and  unimportant 
interlude. 

Symptomatic  Insanity  may  be  logically  divided 
according  to  the  kind  of  disease  of  which  it  is  a  symptom, 
and  thus  falls  naturally  into  the  following  classes  : 

A.  Insanity  symptomatic  of  what  may  be  termed 
intrinsic  diseases,  by  which  I  mean  diseases  due  to 
errors  of  metabolism  and  the  faulty  action  of  glandular 
bodies.  Under  this  head  fall  the  insanity  of  gout,  of 
myxoedema,  of  Graves'  disease,  of  uraemia,  and  so 
forth. 

B.  Insanity  symptomatic  of  what  may  be  termed 
extrinsic  diseases,  by  which  I  mean  diseases  due  to 
poisons  invading  the  body  from  without.  These  are 
subdivisible  according  as  the  poison  is  a  toxin,  produced 
by  a  living  microbe  within  the  body,  or  a  chemical 
poison  ingested  as  such. 

1.  To  the  first  sub-class  belongs  the  insanity  or 
delirium  of  acute  specific  fevers,  of  tuberculosis,  probably 
of  pellagra,  and  so  forth. 


214  A  TEXT-BOOK  OF  INSANITY 

2.  To  the  second  sub- class  belongs  the  insanity  pro- 
duced by  alcohol,  by  opium,  by  cocaine,  and  by  other 
drugs. 

C.  Insanity  symptomatic  of  gross  brain  disease,  by 
which  I  mean  structural  disease  that  is  manifest  to  the 
naked  eye.  This  class  includes  general  paralysis,  post- 
hemiplegic insanity,  insanity  symptomatic  of  tumour  of 
whatever  character  in  the  brain,  and  insanity  due  to 
mechanical  injury  to  the  brain  from  violence. 

D.  Insanity  symptomatic  of  epilepsy,  or  rather  of  the 
disorder  of  brain  of  which  epilepsy  is  a  co-ordinate 
symptom.  What  this  disorder  is  we  do  not  know.  It 
may  perhaps  in  some  cases  be  an  intrinsic  poison ;  it 
is  in  some  cases  mechanical  injury,  or  the  result  of 
mechanical  injury ;  but  whatever  its  nature  may 
ultimately  be  discovered  to  be,  in  the  present  state  of 
our  knowledge  it  must  be  placed  in  a  separate  class. 

Idiopathic  Insanity  is  that  w^hich  is  not  at  present 
known  to  be  symptomatic  of  any  bodily  disease.  It  is 
quite  probable  that  some  of  the  cases,  and  even  some  of 
the  classes,  that  we  must  now  consider  idiopathic,  may 
by  the  progress  of  our  knowledge  be  ultimately  dis- 
covered to  be  symptomatic  of  the  invasion  of  some 
toxin.  If  and  when  this  happens  these  cases  or  these 
classes  will  be  removed  from  the  class  of  idiopathic 
insanity  to  the  class  of  symptomatic  insanity  ;  but  the 
fact  that  they  were  wrongly  classed  will  not  invalidate 
the  scheme  of  classification,  any  more  than  the  dis- 
covery, that  certain  organisms  at  one  time  believed  to 
be  animals  are  really  plants,  invalidates  the  division  of 
organisms  into  plants  and  animals.  The  scheme  of 
classification  will  still  hold  good,  even  though  some  of 
its  contents  may  be  shifted  from  one  place  to  another. 


IDIOPATHIC  INSANITY  215 

Idiopathic  insanity  is  primarily  divided  into  cyclical 
insanity  and  non- cyclical  insanity.  By  cyclical  insanity 
is  meant  insanity  that  runs  a  cyclical  course,  such  that 
the  form  that  it  once  displays  is  departed  from,  and 
replaced  by  some  other  form,  or  perhaps  by  an  interval 
of  sanity,  but  at  length  the  original  form  reappears,  to 
be  followed  by  the  same  phases  in  the  same  order  as  they 
followed  its  first  appearance,  and  the  cycle  may  be 
repeated  again  and  again.  Non-cyclical  insanity  is,  of 
course,  that  in  which  no  such  cyclical  course  can  be 
detected. 

Cyclical  insanity  may  be  divided  into  several  kinds, 
according  to  the  phases  that  occur,  and  to  the  order  in 
which  they  occur.  When  the  several  phases  or  forms 
of  insanity  are  separated  by  intervals  of  sanity,  the 
disease  is  called  recurrent  insanity,  but  there  are  other 
cases  of  cyclical  insanity  in  which  there  are  no  such 
interruptions.  These  are  clearly  allied  very  closely  to 
recurrent  insanity,  but  to  call  them  recurrent  insanity 
would  be  a  misnomer  :  they  may  appropriately  be 
called  circular  insanity,  but  this  name  is  often  given  to 
recurrent  insanity.  All  these  allied  varieties  may 
properly  be  included  under  cyclical  insanity. 

Non-cycUcal  insanity  is  primarily  divided  according  as 
we  are  or  are  not  able  to  correlate  it  with  a  causal  stress, 
to  which  it  is  in  part  attributed.  Some  cases  of  riion- 
cyclical  insanity  arise  apparently  spontaneously,  in- 
dependently of  any  assignable  causal  stress.  The  term 
stress  was  imported  by  me  about  five-and-twenty  years 
ago  from  the  science  of  engineering  into  the  science  of 
alienism,  and  was  used  by  me  in  a  certain  restricted 
meaning  which  is  explained  in  the  chapter  on  causation 
supra.  The  term  has  since  been  used  by  others  in 
difierent  senses,  but  is  here  used  in  the  same  sense  as 


216  A  TEXT-BOOK  OF  INSANITY 

that  which  I  originally  gave  to  it.  Other  cases  of 
non-cyclical  insanity  arise  in  circumstances  that  we  may 
regard  as  productive  of  stress  ;  and  these  cases  we  may 
separate  from  the  others  and  put  in  a  distinct  class. 

A.  Of  the  cases  of  non-cyclical  insanity  to  which  we 
can  assign  no  stress  as  a  contributing  cause,  there  are 
two  main  classes,  viz.  those  that  exhibit  in  some  fixed 
and  enduring  delusion  or  delusions  a  predominant 
feature,  and  those  that  exhibit  no  such  predominant 
feature,  but  consist  in  a  general  degradation  of  conduct 
and  of  mind. 

1 .  The  first  kind  of  non-cyclical  insanity  in  which  there 
is  no  assignable  causal  stress  is  distinguished  by  the 
predominance  of  enduring  delusion  or  delusions,  which 
is  compatible  with  a  high  general  level  of  intelligence. 
It  is  divisible,  according  to  the  character  of  the  pre- 
dominating delusion,  into  three  sub- classes. 

(a)  The  predominating  delusion  is  of  a  persecutory 
plot  against  the  deluded  person.  This  is  the  character- 
istic feature  of  paranoia. 

(h)  The  predominating  delusion  is  of  the  exalted 
rank  or  position  of  the  patient.  These  cases  have  no 
name,  but  are  called  cases  of  fixed  exalted  delusion. 
The  term  megalomania  might  with  advantage  be 
restricted  to  them. 

(c)  The  predominating  delusion  is  of  some  bodily 
change  or  infestation,  of  which  examples  have  been 
given  on  a  previous  page  (p.  153).  They  may  be  appro- 
priately called  cases  of  somatic  delusion. 

2.  The  second  kind  of  non-cychcal  insanity  in  which 
there  is  no  assignable  causal  stress  exhibits  no  delusion 
as  a  predominant  feature,  though  delusions  of  some 


DEMENTIA  217 

kind  or  other  may  be  entertained.  The  insanity  con- 
sists in  a  general  degradation,  though  not  necessarily  a 
uniform  degradation,  of  all  the  faculties  of  mind  and  all 
departments  of  conduct,  and  the  general  and  appro- 
priate name  is  Dementia,  of  which  there  are  the  following 
sub-classes. 

{a)  The  disease  begins  in  an  attack  of  acute  insanity, 
which  may  be  of  any  type,  and  may  or  may  not  have 
belonged  to  the  second  great  class  of  idiopathic  insanity, 
that,  namely,  to  which  a  causal  stress  can  be  assigned. 
This  is  the  kind  of  insanity  known  as  terminal  dementia. 

(b)  The  second  kind  of  dementia  is  that  which  does 
not  follow  an  attack  of  acute  insanity,  but  begins 
slowly,  it  may  be  very  insidiously,  and  gradually 
progresses.  Many  years  ago  the  appropriate  name  of 
Primary  Dementia  was  given  to  these  cases.  They 
would  now  all  be  called  Dementia  Prsecox,  and  would  be 
included  with  an  omnium-gatherum  of  other  cases 
under  this  title. 

This  sub-class  is  again  divisible  into  two  distinct 
varieties  according  as  it  begins  in  early  life  or  middle 
life.  The  latter  variety  has  peculiarities  which  mark 
it  of!  from  the  former. 

B.  The  second  main  class  of  non-cyclical  idiopathic 
insanity  consists  of  those  cases  which  occur  at  a  time  of 
stress,  and  in  which  the  stress  may  reasonably  be  assigned 
as  a  causal  factor.  Stresses  are  of  three  kinds ;  the  first 
is  a  direct  stress,  the  second  we  may  call  physiological, 
since  it  is  an  incident  in  the  progress  of  the  life  of 
everyone,  and  the  other  we  may  call  reproductive,  since 
it  arises  out  of  the  function  of  reproduction. 

1.  The  direct  stresses  that  may  be  assigned  as  causes 
of  idiopathic  insanity  exclude,  of  course,  those  which 


218  A  TEXT-BOOK  OF  INSANITY 

co-exist  with  the  insanity.  In  such  cases  the  insanity 
is  symptomatic,  and  we  are  here  concerned  with  idio- 
pathic insanity.  In  idiopathic  insanity  the  stress  must 
have  ceased  to  act,  and  in  this  sub-class  is  the  insanity 
that  is  left  behind  by  previous  stresses  that  are  now 
absent,  such  as  the  insanity  that  follows  acute  specific 
fevers,  and  that  which  is  left  by  long  continued  alcoholic 
excess. 

2.  The  second  sub-class  of  the  second  kind  of  non- 
cycHcal  insanity  consists  of  those  cases  which  occur  at 
the  time  of  some  physiological  stress,  and  to  which  we 
can  reasonably  assign  this  stress  as  a  causal  agent, 
seeing  that  case  after  case  of  the  same  kind  occurs 
in  the  same  connection.  Physiological  stresses  are 
three. 

(a)  A  certain  number  of  cases  of  insanity  or  of 
"  nervous  breakdown "  of  the  nature  of  insanity, 
though  less  in  degree,  occur  in  connection  with  unduly 
rapid  growth  in  children,  usually  about  the  age  of 
fifteen. 

(6)  The  period  of  adolescence,  that  is  to  say,  from 
seventeen  to  four  or  five-and-twenty,  is  a  period  of 
stress,  and  a  time  of  life  at  which  many  cases  of  insanity 
occur. 

(c)  The  third  period  of  physiological  stress  is  the 
climacteric,  the  period  of  involution  of  the  sexual 
function  in  women,  and  occurs  between  the  ages  of 
forty-five  and  fifty-five. 

3.  The  third  sub-class  of  the  second  kind  of  non- 
cycUcal  insanity  consists  of  the  cases  that  occur  in 
connection  with  the  stress  of  reproduction.  They  also 
may  be  divided  into  three. 


KINDS  OF  INSANITY  219 

(a)  Insanity  during,  and  presumably  due  to,  preg- 
nancy. 

(6)  Insanity  at  or  soon  after  childbirth, 
(c)  Insanity  during  lactation. 

Set  out  as  a  complete  scheme,  the  classification  of 
insanity  the  disease,  as  distinguished  from  insanity  the 
symptom,  and  from  the  type  (acute  or  chronic)  that  the 
insanity  may  assume,  is  as  follows  : — 

Kinds  of  Insanity 
(insanity  the  disease) 

I.  Insanity  of  undevelopment,  or  Involute  Insanity — 

A.  Developmental : 

General. 
Moral  only. 

B.  Metabolic  : 

Cretinism. 

Microcephaly. 

Mongolism. 

C.  Accidental : 

Toxic. 
Traumatic. 

II.  Insanity  of  Dissolution — 

A.  Symptomatic : 

1.  Of  intrinsic  disease. 

2.  Of  extrinsic  disease. 

(a)  Toxic. 
(h)  Poisonous. 

3.  Of  gross  brain  disease. 

4.  Of  mechanical  injury. 

5.  Of  epilepsy. 


220  A  TEXT-BOOK  OF  INSANITY 

B.  Idiopathic  : 

1.  Cyclical. 

2.  Non-cyclical. 

A.  Without  assignable  causal  stress. 

(a)  With  predominating  delusion. 
a.  Of  persecution, 
yg.  Of  exaltation. 
y.  Of  bodily  change. 

(h)  With  no  predominating  de- 
lusion. 

a.  Beginning  in  acute  insanity 
^.  Beginning  gradually. 

(a)  In  early  life. 

(h)  In  middle  life. 

B.  With    assignable    causal    stress, 

which  is  : 

(a)  Pathological. 
a.  Alcohol. 
p.  Specific  toxin. 

(h)  Physiological. 

a.  In  childhood. 
^.  In  adolescence. 
y.  At  the  climacteric. 
S.  In  old  age. 

(c)  Keproductive.  ^ 

a.  Pregnancy. 
/3.  Childbirth, 
y.  Lactation. 

This  is  the  classification  of  the  disease  of  insanity ; 
but  it  is  to  be  remembered  that  this  table  is  to  be  read 
and  used  in  connection  with  the  forms  of  insanity 


FOKMS,  TYPES  AND  KINDS  221 

already  described  in  a  previous  chapter,  and  with  the 
type  of  the  insanity  as  acute  or  chronic.  It  is  the 
endeavour  to  combine  the  form,  the  type  and  the  kind, 
variety,  or  disease  of  insanity  in  a  single  scheme,  and  to 
divide  insanity  simultaneously  on  all  three  principles, 
that  has  vitiated  and  rendered  invalid  every  previous 
scheme  of  classification  ;  but  though  the  three  principles 
cannot  be  used  simultaneously  for  the  purpose  of 
classifying  insanity,  this  is  no  reason  why  each  disease 
or  variety  should  not  have  its  ow^n  form  or  forms,  and 
should  not  be  of  one  or  other  type.  Some  varieties,  such 
as  paranoia,  are  of  the  same  form  and  the  same  type 
throughout,  and  never  vary  in  these  respects.  General 
paralysis,  on  the  other  hand,  may  begin  as  an  acute 
insanity,  or  may  begin  gradually  and  insidiously.  Its 
form  may  be  at  first  euphoric  and  exalted,  or  dysphoric 
and  abased,  or  merely  confused  and  amnemonic ;  and 
subsequently  its  type  becomes  chronic  and  its  form 
anoiac.  In  every  case  the  form  is  easy  to  observe,  the 
type  may  be  readily  ascertained,  but  the  variety  may 
be  long  in  doubt ;  the  reason  being  that  the  form  and 
type  are  chiefly  to  be  ascertained  by  observation,  while 
the  variety  rests  upon  induction,  the  data  for  which  are 
not  always  to  be  had.  There  are  varieties  of  insanity 
that  have  but  one  form :  such  are  paranoia  and  acute 
delirium  ;  and  there  are  forms  that  are  never  seen  but 
in  one  variety:  such  are  stubbornness  and  somatic 
delusion,  or  even  in  only  one  sub- variety,  such  as  the 
delirium  of  belladonna  poisoning ;  and,  on  the  other 
hand,  there  are  forms,  such  as  the  combination  of 
dysphoria  and  abasement,  that  appear  in  many  varieties, 
and  are  not  characteristic  of  any.  This  combination  is 
one  of  the  many  insanities  that  go  by  the  name  of 
melancholia,  and  we  may  see  from  its  distribution  over 


222  A  TEXT-BOOK  OF  INSANITY 

many  varieties  how  much  confusion  the  name  melan- 
cholia is  responsible  for.  Mania  also  is  not  an  inaccurate 
term  as  applied  to  a  form  or  symptom  of  insanity,  and 
as  a  symptom  may  appear  as  a  phase  of  many  varieties, 
but  to  regard  it  as  itself  a  variety  is  to  court  confusion. 
It  is  repeating  the  error  of  the  old  physicians  who 
regarded  cough  and  dropsy  as  diseases. 


INSANITY  OF  INVOLUTION 

By  this  is  meant  those  varieties  of  insanity  that 
result  from  imperfection  in  the  process  of  evolution  or 
development.  The  process  of  development,  instead  of 
going  on  to  produce  a  brain  of  full  adult  development 
in  a  body  of  adult  stature,  for  some  reason  ceases  pre- 
maturely, and  produces  only  an  infantile  or  childish 
brain  in  a  body  of  normal  stature,  or  it  may  be  that  the 
bulk  of  body  also  is  deficient,  and  the  result  is  a  childish 
or  infantile  brain  in  the  body  of  a  dwarf.  It  is  known, 
and  a  good  many  examples  are  on  record  of  the  reverse 
mal-development,  in  which  the  brain  reaches  adult 
development  while  the  body  remains  childish.  In- 
fantilism, as  it  is  called,  is  manifestly  the  reverse  of 
imbecility,  and  as  infantilism  is  believed  to  be  due  to 
defect  of  that  potent  and  mysterious  agency,  the  secretion 
of  some  ductless  gland,  it  might  be  supposed  that 
imbecility,  and  its  extreme  degree  idiocy,  is  due  to  the 
excess  of  the  same.  There  is  no  evidence  that  it  is  not, 
but  it  is  safer  to  assume,  for  it  accords  better  on  the 
whole  with  the  facts,  that  it  is  due  to  mere  premature 
extinction  of  the  process  of  development. 

The  zygote  is  the  product  of  the  fusion  of  a  sperm 
cell  with  a  germ  cell.  To  this  compound  the  germ  cell 
contributes  the  matter  or  substance,  the  sperm  cell 


INVOLUTE  INSANITY  223 

contributes  the  energy  that  animates  the  matter.  The 
one  is  the  mass  of  coals  in  the  grate,  the  other  is  the 
match  that  sets  them  alight ;  or  rather,  the  one  is  the 
dough  in  the  kneading  trough,  the  other  is  the  yeast 
that,  minute  in  quantity  as  it  is  in  comparison,  yet 
permeates  the  dough  throughout  and  sets  it  all  ferment- 
ing. Once  started  by  the  impetus  given  by  the  sperm  at 
conception,  the  zygote  continues  on  its  predetermined 
course  of  development  until  adulthood  is  reached,  and 
even  then,  the  brain  continues  to  develop  until  late  in 
life.  If  the  dough  is  insujficiently  kneaded,  there  will  be 
parts  of  it  to  which  the  yeast  does  not  penetrate,  and 
when  the  bread  is  baked,  these  will  be  recognisable  as 
lumps  of  "  sad  "  bread  embedded  in  the  loaf.  It  seems 
as  if  in  some  cases  parts  of  the  germ  similarly  escape  the 
energising  process  set  going  by  the  sperm  cell,  and  in 
these  parts  development  ceases  before  it  is  complete. 
Thus  we  account  for  spina  bifida,  for  hare  lip,  cleft 
palate,  and  some  other  local  failures  of  development. 
But  when  the  total  impetus  given  by  the  sperm  is  lacking 
in  vigour,  there  will  be  a  general  failure  of  development, 
and  this  may  show  itself  in  imperfect  development  of 
either  of  the  two  main  branches  of  development,  or  in 
both.  Of  course,  in  either  case  it  will  be  the  last  part  of 
development  that  will  fail.  When  a  ball  is  hit  with  the 
bat,  the  distance  that  it  goes  will  depend  on  the  strength 
of  the  impetus  it  receives  from  the  bat.  A  powerful 
impetus  will  drive  it  far,  a  feeble  impetus  will  drive  it 
less  far.  So  with  the  impetus  the  germ  receives  from  the 
sperm.  A  powerful  impetus  will  drive  it  to  the  boundary 
of  the  normal ;  a  more  powerful  impetus  will  drive  it 
beyond  the  normal  to  giantism  on  the  one  hand,  or 
genius  on  the  other,  according  as  the  body  at  large  or 
the  brain  alone  receives  the  chief  share  of  driving 


224  A  TEXT-BOOK  OF  INSANITY 

power.  In  exceptional  cases,  genius  and  giantism  may- 
go  together,  as  in  Charlemagne,  who  was  seven  feet 
high.  More  often  the  brain  develops  at  the  expense,  to 
some  extent,  of  bulk ;  and  most  men  of  high  intelligence 
have  been  men  of  small  stature.  But  when  the  impetus 
is  deficient,  it  is  the  brain  that  will  fail  to  reach  full 
development,  and  it  may  cease  to  develop  after  infancy, 
when  the  result  will  be  idiocy  ;  or  after  early  childhood, 
when  the  result  will  be  imbecility ;  or  after  late  childhood 
or  adolescence,  when  the  result  will  be  f  eeble-mindedness 
in  its  various  degrees.  Such  cases  form  the  class  of 
genetous  idiots  and  imbeciles  of  Bucknill  and  Tuke. 

The  developmental  impetus  which  the  germ  receives 
at  conception  does  more  than  merely  carry  on  develop- 
ment to  completion  of  structure.  It  also  gives  that 
constitutional  vigour  to  which  no  more  definite  name 
can  be  given,  which  enables  the  product  to  withstand 
fatigue  and  to  preserve  all  its  organs  in  balance  and  in 
vigour.  At  conception  the  clock  of  life  is  wound,  and 
the  number  of  years  it  shall  run  is  determined  by  the 
amount  of  the  winding.  Some  are  so  wound  that  the 
clock  runs  down  before  birth,  or  shortly  after,  and  the 
foetus  perishes  in  utero  or  the  child  soon  after  birth, 
from  no  definite  malady,  but  from  mere  insufficiency  of 
"  vital  power."  It  is  ''  not  viable."  In  others  the 
clock  is  wound  to  go  for  a  hundred  years  or  more,  but 
sooner  or  later  the  developmental  impetus  is  exhausted, 
and  then  the  organism  dies,  of  old  age,  as  we  say.  I 
think  there  is  good  evidence  to  show  that  the  develop- 
mental impetus,  if  by  this  we  mean  the  energy  that 
sui!uses  the  organs  of  the  body  and  enables  them  to 
perform  their  functions  and  to  preserve  the  integrity  of 
their  structure,  never  fails  quite  equally,  so  that  all 
the  organs  and  tissues  grow  old  together  and  simul- 


IDIOCY  AND  IMBECILITY  225 

taneously  fail  in  the  performance  of  their  functions.  In 
one  the  arteries  go  first ;  in  another  the  heart  is  the  first 
to  fail  under  the  stress  of  life  ;  and  in  a  third  the  brain 
fails  in  its  functions  while  the  rest  of  the  body  is  still 
vigorous  ;  but  this  thesis  will  be  more  appropriately 
resumed  in  a  later  chapter. 

This  is  the  appropriate  place  to  explain  the  difference 
between  idiocy  and  imbecility,  by  a  distinction  that  I 
first  put  forward  five- and- twenty  years  ago,  but  that  is 
only  now  become  accepted  in  consequence  of  its  em- 
bodiment in  the  Mental  Deficiency  Act.  It  had  long 
been  agreed  that  imbecility  and  idiocy  are  two  degrees, 
less  and  greater,  of  the  same  defect,  but  no  definite  line 
was  drawn  between  them.  The  line  of  division  that  I 
proposed  was  this :  that  imbeciles  are  capable  of 
acquiring,  and  do  acquire,  those  modes  of  conduct  that 
I  have  described  in  the  first  chapter  under  the  heading 
of  directly  self-conservative  activities,  but  are  incapable 
of  acquiring  those  indirectly  self-preservative  activities 
by  which  the  livelihood  is  gained  and  the  means  are 
administered.  Idiots  are  incapable  of  acquiring  even 
the  first  and  simplest  and  most  elementary  modes  of 
conduct.  Supposing  that  there  is  enough  of  inherent 
energy  to  keep  the  machine  going  for  a  few  years,  there 
may  yet  not  be  enough  to  carry  on  the  process  of 
development  to  its  normal  conclusion.  The  whole  of 
what  energy  there  is  is  exhausted  in  the  effort  to  keep 
life  going,  and  none  is  left  available  for  the  increase  of 
life.  Idiots  of  this  origin — "  developmental  idiots  "  or 
"  genetous  idiots,"  as  they  are  called — give  evidence  of 
their  defect  in  other  ways.  They  are  always  short-lived. 
For  the  contest  between  integration  and  disintegration, 
of  which  every  life  consists — a  contest  in  which  integra- 
tion at  first  predominates,  at  first  with  increasing  and 

Q 


226  A  TEXT-BOOK  OF  INSANITY 

then  with  slackening  vigour,  then  for  a  long  while 
maintains  an  equal  footing,  and  at  length  yields  with 
ever  diminishing  vigour  to  disintegration — the  idiot  is 
so  inadequately  equipped  that  the  turning  point  occurs 
long  before  his  full  equipment  is  attained.  The  taper  of 
his  life  burns  so  feebly  that  it  is  only  by  sedulous 
care  that  it  can  be  maintained  even  for  a  few  years ; 
and  before  he  reaches  his  teens  some  of  the  many 
maladies,  which  healthy  children  live  through  without 
difficulty  and  without  detriment,  extinguish  his  little 
flame.  The  idiot  never  develops  more  intelligence 
than  is  possessed  by  the  normal  infant.  Even  at  ten 
or  twelve  5^ears.  if  he  live  so  long,  he  may  not  be  left 
alone  without  immediate  danger  to  his  life.  Even 
physically,  it  is  long  before  he  emerges  from  babyhood. 
He  lies  helpless  in  his  cradle  for  years  after  other 
children  of  his  age  are  running  about  and  at  boisterous 
play.  In  many  cases  he  never  attains,  in  no  case  does 
he  attain  until  several  years  old,  the  command  over  his 
sphincters  and  the  intelligence  to  pass  his  excrements 
appropriately  ;  and  the  ability  to  prehend  his  food  and 
carry  it  to  his  mouth  is  similarly  delayed,  or  similarly 
unattained. 

Idiots  are  always  short-lived,  though  they  not  in- 
frequently reach  adult  age.  They  are  always  lacking 
in  general  and  sustained  vigour  of  movement,  and  as  the 
simplicity  and  want  of  development  of  their  conduct 
expresses  the  simplicity  of  structure  and  want  of  de- 
velopment of  their  brains,  so,  we  may  well  suppose,  does 
the  feebleness  of  their  conduct  and  movement  generally 
indicate  a  want  of  vigour  in  their  cerebral  processes. 
The  same  want  of  vigour  characterises  the  action  of  all 
their  organs  and  tissues.  They  are  feebly  compacted 
and,  as  it  were,  only  half  finished.    All  their  functions 


IDIOCY  AND  IMBECILITY  227 

are  debilitated  and  easily  deranged.  Consequently  they 
have  little  power  of  withstanding  the  action  of  adverse 
agents,  and  early  fall  a  prey  to  disease. 

In  imbeciles  the  vigour  of  development  is  greater, 
often  much  greater.  Their  brains  are  arrested  in  de- 
velopment in  childhood,  but  their  bodies  may  be 
vigorous,  and  they  may  live  to  old  age.  Imbecile 
conduct  has  been  described  on  a  previous  page  (169) 
and  the  description  need  not  be  repeated  here. 

Why  the  union  of  sperm  and  germ  should  result  in  a 
zygote  lacking  in  developmental  vigour  is  not  easy  to 
determine,  and  is  for  the  most  part  matter  of  speculation, 
but  a  few  causes  may  be  assigned  with  some  degree  of 
probability. 

I  have  seen  a  good  many  cases  that  have  convinced 
me  that  children  conceived  near  the  limit  of  the  age  of 
reproduction  in  either  parent  are  apt  to  be  imbecile,  if 
not  idiotic.  Weismannites  will  declare  that  this  is 
a  priori  impossible,  but  a  priori  impossibilities  must  go 
down  before  clinical  experience.  There  seems  some 
reason  to  suppose  that  great  intemperance  on  the  part 
of  either  parent  may  be  a  cause  of  imbecility  in  the 
offspring,  but  there  is  no  proof  of  this.  On  a  priori 
grounds  it  seems  likely  that  the  reproductive  cells 
become  enfeebled  after  long  and  exhausting  illness  of 
those  who  contain  them  ;  but  facts  in  support  of  this 
view  are  wanting. 

In  many  cases,  probably  in  most  cases,  of  involute 
insanity,  development  does  not  expire  from  mere  want 
of  impetus,  but  is  cut  short  prematurely  by  some  inter- 
ference of  a  quasi-accidental  character. 

A.  The  first  of  these  is  deficiency  of  some  glandular 
secretion,  the  presence  of  which  in  sufficient  quantity  is 
necessary  to  normal  development.    The  peculiarity  of 


228  A  TEXT-BOOK  OF  INSANITY 

this  defect  is  that  its  incidence  leads  to  a  number  of 
correlated  changes  in  different  parts  of  the  body,  to  a 
peculiar  physiognomy,  in  which  all  the  cases  resemble 
one  another  so  closely  that  they  might  pass  for  brothers 
and  sisters  of  each  other.  There  are  three  such  cor- 
relative changes,  in  only  one  of  which,  cretinism,  has 
the  substance  whose  deficiency  causes  the  change  been 
identified. 

In  cretinism  the  stature  is  stunted,  the  features  are 
bloated,  the  belly  large,  the  limbs  thick  and  clumsy,  the 
skin  coarse,  thick,  and  pale,  the  hair  scanty,  short,  and 
brittle,  and  the  whole  aspect  so  characteristic  that, 
once  seen,  it  is  easily  recognised.  The  condition  is  due 
to  deficiency  of  the  secretion  of  the  thyroid. 

The  second  kind  of  correlated  change  that  exhibits 
idiocy  is  microcephaly,  the  most  characteristic  feature  of 
which  is  the  extreme  smallness  of  the  cranium,  indicated 
by  the  name,  a  defect  which  is  the  more  conspicuous 
since  it  is  not  shared  by  the  face,  which  is  of  normal 
size  except  the  forehead.  The  hair  is  unusually  coarse 
and  thick,  the  stature  diminutive,  the  nose  aquiline,  the 
eyes  are  rather  large,  the  movements  are  lively,  and 
usually  very  mimetic.  They  imitate  the  attitudes  and 
gestures  of  those  around  them  ;  and  they  are  subject  to 
outbreaks  of  rage  on  slight  provocation.  The  secretion 
to  whose  defect  these  peculiarities  are  due  has  not  yet 
been  identified — perhaps  because  it  has  not  been  sought 
for.  When  it  is  sought  and  found,  microcephaly  will  be 
as  amenable  to  treatment  as  cretinism  now  is. 

The  third  of  the  sets  of  correlated  changes  is  seen  in 
what  the  late  Dr.  Langdon  Down  termed  mongolian 
idiocy,  minor  degrees  of  which  are  far  from  rare.  In 
this  form  also  the  stature  is  low.  The  fades  is  peculiar, 
and  easily  recognised  by  the  small,   obhque,   widely 


IDIOCY  AND   IMBECILITY  229 

separated  palpebral  openings,  the  rounded  ears,  the 
depressed  nose,  and  the  large  and  fissured  tongue.  In 
addition  the  fingers  are  stumpy.  Like  the  microcephalics 
they  are  imitative,  though  to  a  less  degree,  and  for 
idiots  they  are  unusually  teachable.  Since  the  same 
group  of  characters  is  seen  again  and  again  in  case  after 
case, we  are  warranted  in  correlating  them,  and  attribut- 
ing them  to  a  common  cause,  which  is,  it  cannot  well  be 
doubted,  the  want,  or  perhaps  the  excess,  of  some 
chemical  product  of  metabolism. 

B.  The  second  cause  of  premature  arrest,  as  dis- 
tinguished from  premature  cessation,  of  development 
may  be  termed  accidental,  in  that  it  takes  its  origin 
outside  the  body,  and  is  of  the  nature  of  an  interference 
from  without.  The  earliest  in  point  of  time  is  an  intra- 
uterine infection,  and  the  classical  example  is  syphilis. 
It  seems  probable  that  small-pox,  which  is  known  to 
occur  in  utero,  and  perhaps  other  specific  fevers,  may 
have  the  same  effect,  but  evidence  is  wanting.  That 
congenital  syphilis  may  cause  youthful  general  paralysis 
is  now  a  commonplace,  and  a  certain  small  proportion 
of  idiots  and  imbeciles  present  the  stigmata  of  syphiHs. 
In  such  cases  we  assume,  perhaps  on  insufficient  grounds, 
that  the  non-development  of  the  brain  is  due  to  the 
syphilitic  poison.  Idiocy  and  imbecility  not  very 
infrequently  appear  to  date  from  an  attack  of  some 
acute  specific  fever — measles,  scarlatina,  whooping 
cough,  or  perhaps  typhoid — in  childhood.  Allowance 
must  be  made  for  the  difficulty  of  determining  with 
precision  when  a  gradual  process  lilvc  the  development 
of  the  brain  ceases  to  progress.  When  noisy  machinery 
suddenly  stops  we  can  time  the  stoppage  to  a  moment, 
but  a  slow,  silent,  gradual  process  like  cerebral  develop- 
paent  is  less  accurately  timeable ;  and  we  must  remember, 


230  A  TEXT-BOOK  OF  INSANITY 

too,  the  insatiable  craving  of  the  human  mind  to  find 
an  explanation  and  a  cause  for  every  event.  When  it  is 
found  that  a  child's  mind  has  ceased  to  develop,  search 
will  naturally  be  made  in  its  history  for  anything  that 
can  plausibly  be  considered  a  cause,  and  an  attack  of 
specific  fever  will  naturally  be  fixed  upon.  Innumerable 
children  do  suffer  from  such  attacks  without  any  inter- 
ference with  the  ultimate  development  of  their  brains, 
and  therefore  we  must  be  cautious  in  admitting  such 
illnesses  as  causes  of  the  insanity  of  involution  ;  when, 
however,  the  fever  is  attended  by  meningitis,  we  need 
not  be  sceptical.  Meningitis  is  undoubtedly  a  sufl&cient 
cause  of  damage  to  the  cerebral  convolutions. 

Mechanical  injury  also  is  certainly  an  efficient  cause, 
and  is  the  cause  in  many  cases.  Prolonged  pai'turition, 
with  the  pressure  on  the  yielding  bones  of  the  head  that 
it  involves,  sometimes  produces  such  structural  damage 
to  the  brain  that  it  never  recovers  ;  and  instrumental 
delivery  undoubtedly  produces  local  injury  in  some 
cases,  resulting  in  non-development  of  the  motor  area 
on  one  side,  and  consequent  paralysis,  with  imperfect 
development  of  the  limbs,  upon  the  opposite  side.  Cases 
of  congenital  hemiplegia,  with  stunted  growth  of  the 
affected  limbs,  paresis,  and  very  often  with  choreiform 
movements  of  the  affected  side,  spreading,  it  may 
be,  to  the  rest  of  the  body,  are  very  common,  and 
are  always  associated  with  corresponding  imperfection 
in  intelligence,  amounting  to  imbecility  and  some- 
times to  idiocy.  Some  of  these  cases  can  be  assigned 
with  certainty  to  injury  to  the  head  during  birth, 
while  in  others  the  non-development  of  the  convolu- 
tions seems  to  be  due  to  arterial  obstruction  in  early 
life. 

The  condition  just  described  is  frequently  associated 


IDIOCY  AND  EPILEPSY  231 

with  epilepsy,  and  often  epilepsy  without  such  gross 
structural  damage  begins  in  early  Hfe,  and  is  then 
associated  with  mental  defect.  It  is  common  to  speak 
of  the  idiocy  or  imbecility  associated  with  epilepsy 
as  epileptic,  and  if  all  that  is  meant  is  a  convenient 
clinical  description,  the  term  may  be  allowed  ;  but  if 
by  "  epileptic  idiocy  "  be  meant  idiocy  dependent  on 
epilepsy  as  a  cause,  the  appellation  is  unwarranted, 
for  we  do  not  know  whether  the  mental  defect  is  due 
to  the  epilepsy,  or  whether,  as  seems  much  more  likely, 
both  are  manifestations  of  the  same  organic  defect  in 
the  brain. 


CHAPTER   VIII 

INSANITY   OP   DISSOLUTION 

SYMPTOMATIC  INSANITY 

Dissolute  insanity,  or  insanity  the  result  of  dissolution 
of  a  completely  evolved  nervous  system,  we  have  found 
to  be  of  two  main  orders — Symptomatic  insanity,  or 
that  in  which  the  disease  from  which  the  patient  suffers 
is  not  solely  disorder  of  conduct,  mind,  and  brain,  but 
is  a  wider  disorder,  of  which  these  three  disorders  may 
be  regarded  as  symptoms ;  and  Idiopathic  insanity,  in 
which  the  disorder  is,  as  far  as  we  know,  limited  to 
disorder  of  conduct,  mind,  and  brain,  and  to  such  other 
disorder,  as  of  metabolism,  as  is  consequential  to  the 
disorder  of  brain  that  produces  the  insanity.  It  is  the 
diseases  of  the  first  order,  that  of  Symptomatic  insanity, 
that  are  now  to  be  described. 

Symptomatic  insanity  we  have  found  to  be  of  four 
main  kinds,  according  as  the  disease  of  which  the 
insanity  is  a  symptom  is  what  I  have  called  an  intrinsic 
disease,  an  extrinsic  disease,  gross  brain  disease,  or 
epilepsy. 

insanity  symptomatic  of  intrinsic  diseases 
By  intrinsic    diseases   I   mean   diseases    of    faulty 
metabolism,  either  general,  as  in  gout,  or  local,  as  in 
failure  of  the  thyroid. 
Insanity  of  gout. — Gout   is   common :    insanity  of 

232 


INSANITY  AND  GOUT  233 

gout  is  rare.  Still  rarer  is  it  for  insanity  to  accompany 
an  acute  attack  of  podagra.  On  the  contrary,  it  some- 
times happens  that  an  attack  of  insanity  suddenly 
disappears  at  the  very  time  that  gout  appears  in  the 
toe,  and  this  is  the  foundation  of  our  belief  that  the 
insanity  was  due  to  the  action  on  the  brain  of  the  poison, 
whatever  it  is,  which  we  suppose  is  diverted  from  the 
brain  to  the  toe ;  and  thus  we  account  for  the  simultaneous 
disappearance  of  the  insanity  and  appearance  of  the 
podagra.  The  reverse  change,  subsidence  of  the  podagra 
and  simultaneous  occurrence  of  insanity,  has  not,  as  far 
as  I  know,  been  observed.  Without  being  insane,  gouty 
people  are  said  to  be  unusually  irritable  and  irascible 
when  an  attack  of  gout  is  impending,  and  to  resume 
their  normal  equanimity  when  the  poison  becomes 
localised  in  the  toe  or  elsewhere,  and  produces  its 
characteristic  inflammation.  As  a  sufierer  from  gout 
myself,  I  am  able  to  say  that  this  prodromal  change  of 
temper  is  not  universal,  but  the  beUef  in  it  could  scarcely 
have  become  such  a  commonplace  as  it  is  if  there  were 
not  good  ground  for  it.  We  should  naturally  expect 
from  this  notorious  sequence  that  gouty  insanity  which 
is  relieved  by  an  attack  of  gout  would  be  of  the  same 
character,  but  exaggerated;  but  experience  does  not 
bear  out  this  anticipation.  In  the  few  cases  that  have 
been  observed,  the  insanity  was  of  the  form  of  great 
depression. 

Disease  of  the  thyroid  body  produces  two  difierent 
diseases,  myxoedema  and  Graves'  disease,  both  of  which 
may  have  insanity  as  a  symptom. 

The  insanity  of  myxoedema  is  anoia.  The  patient 
subsides  into  great  sluggishness  of  mind  and  conduct. 
Thought  is  slow  and  simple,  memory  is  impaired, 
speech  and  all  movements  are  very  deliberate.    This 


234  A  TEXT-BOOK  OF  INSANITY 

placid  sluggish  condition  is  sometimes  varied  by  fretful- 
ness  and  irritability,  going  on  sometimes  to  actual 
mania,  with  delusions,  usually  of  suspicion,  and  hallu- 
cinations. Myxcedema  is  greatly  improved  by  thyroid 
feeding,  and  the  insanity  improves  along  with  the  bodily 
symptoms ;  but  both  usually  relapse  if  the  thyroid 
feeding  is  discontinued. 

Graves'  disease  is  common  enough,  but  it  rarely 
presents  insanity  as  a  symptom,  and  as  insanity  is  no 
protection  against  Graves'  disease,  nor  Graves'  disease 
against  insanity,  it  is  certain  that  in  the  long  run  the 
two  will  be  found  associated  in  the  same  case.  They 
may  then  be  of  independent  origin,  and  if  so  it  would 
of  course  be  erroneous  to  speak  of  the  insanity  as  sympto- 
matic of  the  Graves'  disease.  We  should  not  be  justified 
in  regarding  the  insanity  concomitant  with  Graves' 
disease  as  symptomatic  of  this  disease  unless  either  the 
two  undergo  concomitant  occurrence,  recovery  or  fluctua- 
tions, or  unless  the  same  form  of  insanity  is  found  in  a 
considerable  number  of  cases  associated  with  Graves' 
disease.  It  can  scarcely  be  said  that  up  to  the  present 
either  of  these  conditions  has  been  satisfied. 

INSANITY   SYMPTOMATIC   OF  EXTRINSIC  DISEASES 

By  an  extrinsic  disease  I  mean,  as  already  explained, 
a  disease  that  is  not  a  gross  disease  and  that  is  due  to  the 
invasion  or  ingestion  of  a  toxic  agent  from  without  the 
body.  Of  such  agents  there  are  two  kinds  :  living 
microbes  and  chemical  poisons. 

INSANITY  SYMPTOMATIC  OF  SPECIFIC  MICROBIC  DISEASES 

Of  these  there  are  two  main  classes,  the  acute  specific 
fevers  and  the  chronic  specific  diseases.    Any  of  these 


INSANITY  AND  FEVER  235 

may,  it  seems,  present  insanity  as  a  symptom  in  some 
part  or  other  of  their  course. 

The  list  of  acute  specific  fevers  is  a  long  one,  including, 
besides  those  indigenous  to  this  and  other  European 
countries,  a  considerable  number  of  others  that  are 
peculiar  to  the  tropical  climate.  Dealing  here  with 
those  only  with  which  English  experience  makes  us 
familiar,  we  may  take  them  together,  since  their  features 
are  for  the  most  part  common. 

Insanity  may  appear  as  a  symptom  of  specific  fever 
at  three  periods  in  the  course  of  the  fever  :  at  the 
invasion,  at  the  height,  and  as  a  sequel. 

That  insanity  may  occur  as  a  symptom  of  the  invasion 
of  a  specific  fever,  such  as  small-pox  or  typhoid,  does 
not  seem  even  yet  to  be  generally  known,  in  spite  of  the 
number  of  times  that  I  have  called  attention  to  it  in  the 
last  twenty-five  years.  At  least  I  find  little  or  no 
reference  to  the  fact  in  the  most  recent  text-books  of 
insanity.  Yet  it  is  a  very  important  possibility  to  bear 
in  mind,  for  if  it  is  not  recognised,  a  patient  in  the 
incubation  or  invasion  stage  of  typhoid  fever  may  be 
sent  to  a  lunatic  asylum,  and  there  not  only  receive 
treatment  inappropriate  to  typhoid  fever,  an  event 
which  has  actually  occurred,  but  also  may  be  the  focus 
of  an  epidemic  of  fever  in  the  asylum.  The  form  of 
insanity  that  occurs  at  the  invasion  stage  of  a  specific 
fever  is  always,  I  believe,  acute  excitement  on  a  low 
level — mania,  as  this  is  called.  It  may  be  preceded  by 
a  few  days  of  malaise,  or  it  may  be  quite  the  first 
symptom  that  is  noticed. 

Insanity  at  the  height  of  the  fever,  that  is  to  say, 
when  the  temperature  has  been  high  for  some  days, 
and  the  patient  is,  as  a  rule,  very  exhausted,  is  called 
(ielirium.    The  mind  is  much  confused ;  there  is  what  is 


236  A  TEXT-BOOK  OF  INSANITY 

sometimes  called  disorientation,  that  is  to  say,  the  patient 
does  not  realise  where  he  is,  or  recognise  familiar  persons 
and  things ;  there  are  often  hallucinations,  mostly  of 
vision ;  and  there  are  agitated  movements,  which,  since 
the  patient  is  extremely  exhausted,  are  not  violent, 
but  are  limited  to  picking  at  the  bed-clothes,  and 
similar  small  movements.  If  the  patient  were  physically 
stronger,  no  doubt  he  would  gabble  and  rave  ;  as  it  is 
his  utterance  is  reduced  by  weakness  to  a  mutter,  and 
*'  muttering  delirium  "  or  "  busy  delirium  "  are  the  terms 
usually  applied  to  his  insanity.  If  he  is  strong  enough 
he  tries  to  get  out  of  bed,  but  he  is  not  often  strong 
enough  to  succeed,  and  if  he  does  succeed  he  usually 
falls  and  lies  on  the  floor.  Cases  have  been  known, 
however,  in  which  patients  in  the  delirium  of  fever  have 
gone  about  the  house,  and  even  out  of  doors,  in  their 
night-clothes,  and  have  wandered  some  distance.  When 
I  first  pointed  out  that  the  delirium  of  fever  is  insanity, 
the  assertion  met  with  a  good  deal  of  ridicule,  but  I  do 
not  know  that  anyone  disputes  it  now. 

There  is  one  acute  specific  fever  of  which  the 
symptomatic  insanity  is  the  most  conspicuous  and  most 
important  symptom,  and  which  is  therefore  not  included 
among  specific  fevers  in  any  book  on  that  subject,  and 
is  included  in  insanity  in  every  book  on  this  subject. 
This  is  the  fever  known  as  acute  delirium  or  acute 
delirious  mania,  which  has  been  described  as  a  type  of 
insanity.  In  this  case,  as  in  the  case  of  stupor,  the 
type  is  coincident  with  the  kind. 

Post-febrile  insanity  is  not  at  all  rare,  especially 
after  influenza,  but  post-febrile  insanity  is  not  sympto- 
matic insanity,  for  when  it  appears  the  fever  is  over 
and  gone,  and  the  insanity  is  no  more  symptomatic  of 
the  fever  that  is  past  than  valvular  disease  of  the  heart 


INSANITY  OF  CHRONIC  INFECTION    237 

is  a  symptom  of  the  acute  rheumatism  that  has  passed 
away  and  left  the  valvular  disease  behind  it.  The  heart 
disease  is  now  raised  from  the  status  of  a  symptomatic 
disease  to  an  independent  primary  disease,  and  so  is 
the  insanity  that  is  left  behind  by  a  fever.  Post- febrile 
insanity  will  therefore  be  considered  infra  among  idio- 
pathic insanities.  It  will  be  noted  that  this  classification 
corresponds  strictly  with  clinical  methods,  for  we  think 
of  pre-febrile  insanity  and  of  febrile  insanity  in  con- 
nection with  the  fevers  of  which  they  are  symptomatic, 
and  treat  them  accordingly  for  the  fever,  in  fever 
hospitals  or  in  their  own  homes  ;  but  in  dealing  with 
post- febrile  insanity,  we  take  note  of  the  fever  as  causa- 
tive, and  then  dismiss  it  from  our  minds,  and  treat  the 
patient,  often  in  an  asylum,  on  the  basis  that  he  suffers 
from  idiopathic  insanity. 

INSANITY  SYMPTOMATIC   OF   CHRONIC   MICROBIC  DISEASE 

This  group  includes  the  insanity  symptomatic  of 
syphilis  (except  general  paralysis)  and  of  tuberculosis, 
which  are  the  chief  chronic  invasions  seen  in  this 
country,  and  in  addition  of  sleeping  sickness,  of  malaria, 
and  as  it  now  appears  of  pellagra,  and  doubtless  of  other 
chronic  infections.  General  paralysis  is  excluded  from 
this  group  and  placed  in  the  next  because,  although  it  is 
due  to  syphilis,  the  insanity  is  symptomatic  of  gross 
brain  disease.  For  the  same  reason  the  insanity  that 
may  attend  cerebral  hydatid  is  similarly  placed.  If 
anyone  is  aggrieved  by  this  arrangement,  it  is  open  to 
him  to  shift  general  paralysis  from  the  position  in  which 
I  have  placed  it  into  this  group,  and  I  don't  know  that 
any  particular  harm  will  be  done.  For  the  same  reason 
the  insanity,  if  any,  that  is  symptomatic  of  tubercular 


238  A  TEXT-BOOK  OF  INSANITY 

tumour  of  the  brain  is  classed  among  those  due  to  gross 
lesions,  to  which  it  belongs  clinically.  It  seems  to  me 
that  there  is  a  clear  difference  between  the  insanity 
symptomatic  of  the  poisoning  of  the  brain  by  a  toxin, 
and  the  insanity  symptomatic  of  a  gross  lesion,  even 
though  the  toxin  and  the  gross  lesion  may  both  be  due 
to  the  same  kind  of  microbe. 

INSANITY  SYMPTOMATIC  OF  TUBERCULOSIS 
Not  every  insanit}^  occurring  in  persons  who  are  also 
tubercular  is  symptomatic  of  tuberculosis.  Phthisis  is 
so  frequent  among  the  insane  that  there  is  little  danger 
of  this  fortuitous  concomitance  being  overlooked ;  but 
alienists  are  not  always  on  their  guard  to  distinguish  causal 
correlation  from  fortuitous  concomitance.  For  instance, 
every  case  of  insanity  that  occurs  in  a  woman  about  the 
climacteric  age  is  called  climacteric  insanity,  which  it 
may  not  be,  and  often  is  not. 

Phthisis  is  common  among  the  insane,  but  apart 
from  this  there  is  a  variety  of  insanity  often  associated 
with  phthisis,  and  assuming  much  the  same  form  in 
the  phthisical  patients  w^ho  become  insane.  The 
insanity  often  precedes  the  physical  signs  of  phthisis, 
and  it  is  quite  possible  to  predict  the  onset  of  phthisis 
from  the  form  that  the  insanity  assumes,  together  with 
the  general  bodily  condition.  The  form  of  the  insanity 
is  always  that  of  sub-acute  insanity  with  depression, 
and  delusions  of  suspicion.  The  common  form  that 
the  suspicion  takes  is  that  of  being  poisoned.  The  patient 
refuses  food,  and  when  the  case  is  investigated,  it  is 
found  that  the  refusal  is  based  upon  suspicion  that  the 
food  is  poisoned.  The  patient  is  feeble,  languid,  idle, 
and  in  addition  is  irritable,  morose,  and  suspicious  to  an 
insane  degree.    All  that  is  done  for  her  (it  is,  I  think. 


INSANITY  OF  SYPHILIS  239 

more  frequent  in  the  female)  is  misinterpreted  and 
attributed  to  evil  motives  and  machinations.  The 
physical  signs  of  phthisis  are  often  not  present  in  the 
lungs  at  first,  but  there  are  loss  of  weight,  feeble  circula- 
tion, coldness  of  the  extremities,  chilblains,  deficiency 
of  sleep,  from  the  beginning ;  and  when  the  physical 
signs  do  appear,  they  usually  progress  rapidly.  In 
many  cases,  however,  the  course  of  the  disease  is  pro- 
tracted. The  prognosis  is  bad,  but  patients  occasion- 
ally recover  from  the  insanity. 

INSANITY  SYMPTOMATIC  OF  SYPHILIS 

Syphilis  and  insanity  are  connected  in  many  ways, 
which  have  been  enumerated  very  completely  by  Sir  G. 
Savage,  but  here  we  are  concerned  with  that  insanity 
only  which  is  symptomatic  of  syphilis,  excluding  general 
paralysis  and  the  insanity  that  results  from  cerebral 
gumma,  which,  as  gross  diseases  of  the  brain,  fall  in  a 
subsequent  class.  It  was  Sir  Jonathan  Hutchinson  who 
first  pointed  out  that  syphilis  is  a  specific  fever,  difiiering 
from  the  acute  specific  fevers  only  in  the  prolongation 
of  its  stages  ;  and  this  general  similarity  may  be  supple- 
mented by  the  further  similarity  that  in  the  eruptive 
stage  of  syphilis,  as  in  the  eruptive  stage  of  acute  specific 
fevers,  the  brain  may  be  so  poisoned  by  the  toxin 
produced  by  the  microbe  that  insanity  results.  Such 
insanity  differs  from  the  delirium  of  acute  specific  fevers 
in  the  absence  of  the  great  bodily  prostration  that  they 
produce.  In  the  eruptive  stage  of  syphilis  the  patient  is 
not  necessarily  so  weak  as  to  be  confined  to  bed,  and  his 
insanity,  if  he  is  insane,  is  correspondingly  of  more 
vigorous  character.  Like  the  delirium  of  acute  specific 
fever,  however,  it  is  an  acute  insanity  of  excited  form, 


240  A  TEXT-BOOK  OF  INSANITY 

and  accompanied  by  hallucination.  It  may  have  any 
of  the  features  and  lead  to  any  of  the  terminations  of 
excited  acute  insanity. 

INSANITY  SYMPTOMATIC  OF  THOSE  EXTRINSIC 
DISEASES   THAT  ARE  DUE   TO  CHEMICAL  POISONS 

Insanity  symptomatic  of  alcoholic  poisoning. — The 
chief  of  these  poisons  is  alcohol,  and  alcohol  pro- 
duces insanity  in  several  ways  and  of  several  kinds, 
according  to  the  quantity  taken,  to  the  length  of  time 
over  which  it  has  been  taken,  and  to  the  character  of 
the  person  by  whom  it  has  been  taken.  When  once  it  is 
recognised  that  drunkenness  is  insanity,  a  proposition 
that  was  received  with  incredulous  amazement  when  I 
first  made  it  five-and-twenty  years  ago,  the  experimental 
insanity  that  is  produced  by  drinking  alcohol  throws  a 
flood  of  light  upon  the  incidence  of  insanity  generally. 
From  it  we  learn,  in  the  first  place,  how  wide  are  the 
variations  in  liability  to  become  insane,  or,  to  put  it 
another  way,  how  various  are  the  degrees  of  resistance 
to  insanity  under  the  same  stress  in  different  persons. 
Some  persons  become  uproariously  drunk  after  taking 
two  or  three  ounces  of  spirit,  others  never  become 
drunk,  however  much  they  may  take.  There  are  men, 
and  women  too,  who  drink  from  a  bottle  to  a  bottle  and 
a  half,  say  from  thirty  to  forty-five  ounces,  of  whiskey 
a  day  without  any  immediate  effect  upon  conduct  or 
mind,  or  with  such  slight  effect  as  can  be  recognised 
only  by  those  who  are  intimately  acquainted  with  them, 
and  so  can  recognise  small  shades  of  variation.  In  the 
second  place,  we  learn  how  much  the  form  of  the  insanity 
depends  on  the  character  of  the  person  who  becomes 
insane.  The  same  amount  of  the  same  form  of  alcohol 
administered  to  several  members  of  a  party  will  perhaps 


INSANITY  AND  ALCOHOL  241 

make  them  all  drunk,  but  the  insanity  of  drunkenness 
will  show  itself  in  each  one  in  a  form  different  from  that 
of  the  others,  as  set  forth  on  a  previous  page,  on 
which  the  various  effects  of  different  quantities  on  the 
same  person  are  also  described.  From  these  diJSerent 
effects  of  the  same  quantity  of  the  same  agent  on 
different  persons  we  may  justifiably  infer  the  material 
identity  of  the  different  forms  of  acute  insanity.  Whether 
this  shall  exhibit  itself  as  depression  (acute  melancholia), 
or  excitement  (acute  mania),  or  stubbornness  (acute 
melanchoha),  or  stupor,  or  some  other  form  is  a  matter 
of  quasi-accident,  depending  in  part  on  the  nature  and 
character  of  the  person  who  becomes  insane,  and  in  part 
on  other  conditions  of  which  we  are  ignorant.  Certain 
it  is  that  the  same  person  may  exhibit,  in  different 
attacks,  or  on  different  occasions,  acute  insanity  of 
different  forms,  showing  first,  how  easily  one  form 
replaces  another ;  and  second,  that  the  character  of  the 
person  affected  is  not  the  only  factor  in  changing  the 
form  of  the  insanity. 

Alcohol  is  responsible  for  two  very  different  kinds  of 
acute  insanity.  The  first  is  the  insanity  of  ordinary 
drunkenness,  the  second  is  delirium  tremens,  which  has 
been  shown  by  Dr.  Francis  Hare  to  be  due  to  the  sudden 
withdrawal  of  the  whole  or  a  great  part  of  the  customary 
daily  quantum  of  alcohol  of  those  who  are  accustomed 
to  take  regularly  a  large  quantity.  Delirium  tremens 
is  a  very  w^ell  characterised  form  of  acute  insanity,  of 
short  duration  and  favourable  issue,  which  it  is  unneces- 
sary to  describe  here,  since  a  description  will  be  found  in 
the  ordinary  text-books  of  general  medicine.  All  that 
is  necessary  to  add  here  is  that  an  attack  of  dehrium 
tremens  can  be  cut  short  with  certainty  at  an  early 
stage  by  the  administration  of  the  customary  dose  of 

R 


242  A  TEXT-BOOK  OF  INSANITY 

alcohol ;  and  that  an  attack  can  infallibly  be  produced 
in  anyone  who  has  for  some  time  been  accustomed  to 
take  large  doses  of  alcohol,  by  cutting  ofi,  or  materially 
diminishing,  the  customary  quantity. 

Alcohol  is  responsible  also  for  at  least  two  types  of 
chronic  insanity,  but  as  these  are  not  due  to  the  presence 
of  the  poison  in  the  brain,  but  are  effects  of  its  previous 
action,  persisting  long  after  all  the  alcohol  has  been 
cleared  out  of  the  body,  they  are  not  Symptomatic  in- 
sanity, but  are  Idiopathic,  and  fall  to  be  described  later 
on.  This  division  corresponds  with  a  clinical  severance, 
for  we  do  not  think  of  together,  nor  treat  in  the  same 
way,  the  acute  insanity  produced  by  the  presence  of  the 
poison  in  the  brain  and  the  chronic  insanity  due  to  the 
damage  that  alcohol  has  inflicted  in  the  past. 


CHAPTER   IX 

SYMPTOMATIC  INSANITY  CONTINUED 

GENERAL   PARALYSIS 

There  is  no  variety  of  insanity  more  distinct  or  more 
important  than  this.  It  is  so  distinct  that  some  years 
ago  a  very  able  writer  on  insanity  divided  this  malady 
into  two  varieties  only — ordinary  insanity  and  general 
paralysis.  Its  importance  lies  in  its  frequency,  in  its 
progressive  and  incurable  character,  and  in  the  frequent 
difficulty  of  its  diagnosis. 

In  the  main,  general  paralysis  is  a  disease  of  middle 
life  and  of  the  male  sex.  It  seems  to  affect  by  preference 
vigorous,  energetic,  successful  men,  who  have  lived  full, 
active,  busy  lives  in  cities  ;  who  are  married  ;  who  have 
indulged  freely  in  eating  and  drinking,  and  in  sexuality  ; 
and  in  whom  an  hereditary  disposition  to  insanity  is 
absent.  While  this  is  the  character  of  the  majority  of 
persons  who  become  the  victims  of  general  paralysis, 
the  malady  is  not  strictly  limited  to  such  persons.  It 
does  occur  also  in  those  who  have  an  insane  inheritance, 
and  about  10  per  cent,  of  general  paralytics  are  thus 
characterised.  It  does  occur  also  in  women,  about 
19  per  cent,  of  the  occurring  cases  affecting  this  sex  ; 
and  in  rare  cases  it  occurs  in  early  Hfe,  in  children  in 
the  early  teens,  and  then  it  is  invariably  found  to  be 
associated  with  hereditary  syphiHs.  So  singular  and 
invariable  an  association  in  these  early  cases  led  to 

243 


244  A  TEXT-BOOK  OF  INSANITY 

strict  inquiry  with  respect  to  the  antecedents  of  general 
paralytics  of  mature  age,  and  it  was  then  found  that 
in  a  very  large  proportion  of  these  also  syphilis  was 
antecedent  to  the  disease.  It  was  found  that  in  80  per 
cent,  there  was  conclusive  proof  of  syphilis,  either  in  the 
history  or  in  stigmata  existing  in  the  body.  In  the 
remaining  20  per  cent,  no  history  or  sign  of  syphilis 
could  be  found,  but  then  it  is  found  that,  with  respect 
to  other  lesions  which  are  unquestionably  syphilitic,  but 
which  occur  long  after  the  infection,  there  is  a  residue 
of  20  per  cent,  in  which  no  history  of  syphilis  and  no 
other  stigmata  of  syphilis  exist.  We  are  therefore 
driven  to  the  conclusion  that  syphilis  is  a  very  constant 
if  not  an  invariable  antecedent  of  general  paralysis,  and 
certainly  the  most  important  factor  in  the  causation  of 
the  disease. 

It  is  certainly  not  the  sole  factor,  however.  Only  a 
very  small  proportion  of  the  persons  who  are  syphilitic 
become  general  paralytics ;  and  in  almost  all  cases  of 
general  paralysis  we  find  that  the  patient  has  recentty 
passed  through  a  period  of  mental  or  other  stress,  which 
has  seemed  to  determine  the  onset  of  the  disease.  He 
has  had  great  anxiety  in  his  business  or  in  his  family ; 
he  has  indulged  too  freely  in  alcohol ;  he  has  had 
influenza  ;  he  has  had  a  blow  on  the  head  ;  or  he  has 
su.ffered  from  some  other  form  of  stress  ;  and  it  seems 
that  it  is  this  provocative  occasion,  acting  upon  a  person 
already  syphilised,  that  determines  the  disease.  It  is 
to  be  remembered  that  general  paralysis  is  closely  allied 
to  tabes  ;  that  tabes  sometimes  culminates  and  termi- 
nates in  general  paralysis  ;  that  true  tabetic  symptoms 
occur  in  general  paratysis  ;  and  that  the  affections  of  the 
oculo-motor  apparatus  in  the  two  diseases  are  closely 
allied.    Hence  we  have  additional  reason  for  expecting 


GENERAL  PARALYSIS  245 

that  the  causes  that  produce  the  one  will  be  closely 
similar  to  those  that  produce  the  other. 

General  paralysis  may  begin  quite  suddenly,  with  a 
fit,  or  with  an  outbreak  of  acute  insanity  of  which  no 
warning  has  been  given  ;  but  usually,  after  the  disease 
has  declared  itself,  it  is  remembered  that  for  days, 
weeks,  or  perhaps  even  months,  the  patient  had  been 
failing  in  certain  assignable  ways.  It  is  rare,  however, 
for  these  warnings  to  be  sufficiently  pronounced  and 
sufficiently  definite  to  enable  us  to  predict,  or  even  to 
suspect,  what  is  coming.  When  it  is  not  sudden,  the 
onset  of  the  disease  is  usually  rapid. 

The  prodromes  may  be  divided  into  four  groups, 
and  are,  in  the  order  of  their  frequency,  moral,  intel- 
lectual, sensory,  and  motor. 

The  most  frequent  of  the  early  changes  of  general 
paralysis  is  a  change  and  a  degradation  of  the  moral 
tone  of  the  individual.  His  character  changes.  Always 
a  busy,  energetic  man,  prone  to  take  risks,  to  keep  late 
hours,  to  live  freely,  all  these  characteristics  become 
accentuated.  His  energy  becomes  overpowering ;  he 
undertakes  more  than  he  can  get  through,  and  his 
affairs  become  more  and  more  involved  and  entanoied  ; 
he  speculates  more  rashly ;  he  goes  about  more  ;  he 
takes  long  journeys  upon  slight  inducement ;  he  drinks 
more  ;  he  is  less  particular  about  his  associates  and 
companions  ;  he  goes  among  loose  women  ;  he  talks  too 
much,  and  chatters  among  strangers  about  his  private 
affairs  ;  he  becomes  effusive  ;  he  gives  presents  with- 
out sufficient  justffication  ;  he  brags.  He  is  like  a  man 
always  a  little  under  the  influence  of  drink  ;  and,  as  he 
does  drink  a  good  deal,  his  peculiarities  are  attributed 
to  drink  alone.  When  this  phase  of  conduct  is  but 
slightly  marked,  it  may  be  considered  as  a  prodrome 


246  A  TEXT-BOOK  OF  INSANITY 

of  the  disease,  but  when  it  is  exaggerated,  it  constitutes 
the  first  stage  of  the  malady  in  one  of  its  forms. 

The  prodromes  on  the  intellectual  side,  in  addition 
to  those  included  in  the  above  description,  consist  of  a 
want  of  mental  efficiency,  more  or  less  marked,  and 
existing  for  a  longer  or  shorter  time  before  the  outbreak 
of  the  disease.  The  patient  becomes  stupid.  He  cannot 
concentrate  his  attention  ;  he  forgets  things  ;  he  makes 
mistakes  ;  he  is  confused  in  his  mind,  and  it  is  apparent 
that  he  is  less  capable  in  business  and  less  able  to 
transact  all  the  affairs  of  life  than  he  was.  When  these 
symptoms  are  but  slight,  they  are  looked  on  as  pro- 
dromes. When  pronounced,  they  constitute  the 
demented  form  of  the  disease. 

Neither  the  pupillary  abnormalities  nor  the  articu- 
latory  troubles,  however  slight  in  degree,  are  counted 
among  the  prodromes  of  general  paralysis.  If  they 
exist  at  all,  we  regard  the  disease  as  established  ;  but 
then  the  pupillary  changes  are  not  seen  until  they  are 
looked  for,  and  they  are  not  looked  for  until  some  more 
prominent  symptom  suggests  general  paralysis.  The 
articulatory  defect,  again,  is  never  a  very  early  symptom. 
Often  the  patient  has  been  consigned  to  an  asylum  for 
months  before  the  defect  of  articulation  shows  itself, 
and  it  never  appears  before  the  mental  symptoms. 
But  before  the  definite  outbreak  of  the  disease  there 
may  be  transient  motor  troubles.  A  limb  may  become 
weak,  or  an  eyelid  may  droop,  or  there  may  be  transient 
aphasia  or  transient  strabismus,  which,  with  a  history 
of  syphilis,  may  give  rise  to  a  suspicion  of  gumma.  The 
handwriting  sometimes  becomes  sprawling  or  shaky, 
but  it  does  not,  in  this  early  stage,  show  the  character- 
istic changes  that  will  be  presently  described.  In  those 
cases  in  which  the  morbid  change  first  attacks  the  cord, 


GENERAL  PARALYSIS  247 

ataxy  of  the  gait  may  be  properly  looked  upon  as  a 
prodrome  of  general  paralysis  ;  but  until  the  insanity 
declares  itself,  there  is  nothing  to  distinguish  such 
cases  from  ordinary  tabes.  Li  rare  cases  there  may,  in 
the  early  stage,  be  a  transient  ataxy  of  gait,  comparable 
with  the  transient  aphasia ;  or  there  may  be  attacks 
of  giddiness,  fainting,  or  purposeless  vomiting.  It  will 
be  seen  from  this  description  that  although,  when  the 
disease  declares  itself,  we  can  recognise  that  such  motor 
symptoms  as  these  were  its  earliest  manifestations,  yet, 
until  the  malady  is  otherwise  recognisable,  there  is 
nothing  in  them  to  point  to  an  oncoming  general 
paralysis,  or  to  lead  us  to  anticipate  its  occurrence. 

On  the  sensory  side,  the  warnings,  if  warnings  they 
can  be  called,  are  similarly  transient,  similarly  isolated, 
and  usually  similarly  sudden.  When  a  patient  is  brought 
to  us  with  definite  general  paralysis,  we  may  learn  that 
during  the  previous  twelve  or  eighteen  months  he  has 
been  treated  for  a  sudden  deafness  of  one  ear,  or  blind- 
ness of  one  eye,  or  for  neuralgia,  or  severe  headache,  or 
for  local  numbness  or  anaesthesia  ;  but  it  is  not  possible 
at  the  time  these  symptoms  occur,  to  predict  that  they 
will  be  followed  by  general  paralysis. 

The  onset  of  the  disease  may  be  sudden,  and  is  usually 
rapid.  Often  it  is  possible  to  assign  the  very  day  upon 
which  the  malady  declared  itself,  either  by  a  fit  of  some 
kind,  or  by  an  outbreak  of  acute  mania.  Often  the 
symptoms,  which  have  been  described  as  moral  or 
intellectual  prodromes,  become  rapidly  exaggerated 
in  intensity  until,  in  the  course  of  a  week  or  so,  the 
apprehension  that  the  patient  may  be  going  out  of  his 
mind  becomes  a  fact  only  too  patent.  In  any  case,  the 
definite  invasion  of  the  disease  is  usually  an  attack  of 
acute  insanity,  and  in  the  majority  of  cases  the  acute 


248  A  TEXT-BOOK  OF  INSANITY 

insanity  is  of  the  maniacal  type.  In  a  minority  of  cases 
the  acute  insanity  of  the  onset  is  melancholic  or  resistive. 
It  is  scarcely  ever  suicidal.  It  is  usually  very  acute,  and 
marked  by  aggression  and  violence.  Sometimes  it  is  so 
acute  as  to  be  taken  for  acute  delirious  mania.  It  lasts 
for  a  few  days,  or  more  often  for  several  weeks,  and  then 
subsides  into  a  sub-acute  insanity  which  exhibits  one 
of  the  following  types  : — 

1.  The  maniacal  or  classical  type. 

2.  The  melancholic  type. 

3.  The  demented  type. 

4.  The  fulminating  type. 

5.  The  circular  type. 

6.  The  spinal  or  tabetic  type. 

1.  The  maniacal  or  classical  type  of  general  paralysis 
is  the  most  distinctive  and  most  striking  of  all  forms  of 
insanity.  In  no  other  form  do  we  witness  such  exag- 
gerated hyperbolical  exaltation.  The  patient  owns 
millions  and  millions  ;  he  is  thousands  of  years  old  ;  he 
has  hundreds  of  wives,  thousands  of  children ;  he  has 
such  titles  as  were  never  heard  of ;  he  is  the  greatest 
inventor,  artist,  poet,  warrior,  statesman,  pitch-and-toss 
player,  the  world  has  ever  seen.  He  is  lavishly  benevo- 
lent ;  he  will  give  cheques  for  millions,  written  on  dirty 
bits  of  newspaper,  to  all  bystanders.  He  talks  inces- 
santly, save  when  he  is  writing ;  and  he  writes  inces- 
santly, save  when  he  is  talking.  He  corresponds,  still 
on  margins  of  newspapers,  or  dirty  scraps  picked  up  in 
the  road,  with  all  the  crowned  heads  of  Europe  and  all 
the  celebrated  people  he  can  think  of.  His  writing  is 
characteristic.  It  is  sprawling  and  shaky  ;  it  is  unrecog- 
nisable as  his  ordinary  handwriting.  He  omits  letters  ; 
he  fails  to  finish  his  words  ;  he  omits  syllables,  and  often 


GENERAL  PAKALYSIS  249 

whole  words.  He  runs  the  words  together  in  writing 
just  as  he  does  in  speech,  and  often  he  repeats  the  same 
word  or  syllable  twice  or  oftener. 

In  this  stage  he  sleeps  little,  he  is  up  early  and  late, 
he  is  full  of  eager,  busy,  futile  activity.  In  whatever 
is  going  on  he  must  take  part,  and  principal  part.  If 
anything  is  being  discussed,  he  lays  down  the  law  ;  if 
anything  is  being  done,  he  takes  the  command.  He 
appropriates  everything  he  has  a  mind  to,  and  when 
his  pockets  are  turned  out,  they  are  found  to  contain 
as  miscellaneous  a  collection  as  a  magpie's  nest — other 
people's  pipes,  handkerchiefs,  and  pencils,  one  or  two 
playing-cards,  bits  of  string,  bits  of  bread,  sticks,  stones, 
dead  leaves,  and  bits  of  paper  innumerable. 

At  the  same  time,  with  all  his  grandeur  and  majesty, 
he  is  singularly  weak  of  will  and  easily  influenced.  In 
his  own  house  he  is  obedient  to  his  own  servants,  if  they 
are  at  once  authoritative  and  judicious.  He  does  what 
he  is  told.  He  is  full  of  preposterous  schemes,  but  he  is 
diverted  from  their  pursuit  with  the  utmost  ease  ;  and 
even  if  left  alone,  he  does  not  pursue  any  one  of  them 
for  more  than  a  few  moments  together.  He  is  subject 
to  outbursts  of  temper,  rising  often  to  fury,  but  they 
are  short-lived  and  easy  to  control.  Sent  to  an  asylum, 
he  accepts  the  situation  without  murmur  and  without 
question.  He  does  not  resent  his  removal  from  home  ; 
he  sees  nothing  worthy  of  protest  or  remark  in  the 
control  to  which  he  is  subjected. 

In  this  excited  and  grandiose  condition  he  remains 
for  a  few  months,  becoming  gradually  calmer  and  more 
demented,  until  at  the  end  of  a  variable  time,  usually 
about  a  year  after  the  onset  of  the  disease,  he  has  a  fit, 
and  then  the  course  of  the  disease  follows  the  order  that 
will  be  presently  described. 


250  A  TEXT-BOOK  OF  INSANITY 

2.  The  demented  type. — In  common  with  other  insane 
persons,  all  general  paralytics  are  anoiac  in  every 
stage  of  their  malady  ;  but  what  is  meant  by  the 
demented  type  of  general  paralysis  is  a  form  of  the 
disease  in  which  the  dementia  is  simple,  and  is  miaccom- 
panied  by  the  active  symptoms  so  characteristic  of  the 
other  forms.  In  the  second  stage  of  the  disease — that 
is  to  say,  after  the  first  fit — the  more  active  symptoms 
subside  in  every  type  of  the  disease,  and  the  case 
approaches  to  one  of  simple  dementia  ;  but  in  the  type 
now  under  consideration  the  symptoms  are  never  very 
active.  The  patient  is  from  the  first  heavy,  stupid, 
lethargic,  inactive ;  whatever  activity  there  is  in  the 
mind  is  of  the  same  cast  as  in  the  classical  type,  and  the 
patient  often  surprises  us  by  evincing  out  of  his  dullness 
some  extravagant  delusion ;  and  just  as  in  the  other 
types  the  period  of  simple  dementia  sets  in  with  the 
fits,  so  in  this  type  fits  occur  early  in  the  course  of  the 
malady  and  are  frequent  during  its  progress.  This  is 
the  form  that  general  paralysis  usually  takes  when  it 
begins  with  a  fit.  As  might  be  expected,  the  course  of 
the  disease  is  more  rapid  than  in  the  classical  type. 

3.  The  melancholic  type. — General  paralysis  usually 
begins  with  an  attack  of  acute  insanity,  and,  as  already 
stated,  the  acute  insanity  of  the  commencement  is 
sometimes  melancholic  or  resistive  in  type.  When  this 
is  so,  the  tinge  of  melancholia  usually  remains  through- 
out the  progress  of  the  disease.  Not  infrequently  a 
case  that  has  begun  with  acute  mania  becomes  sub- 
sequently melancholic.  The  patient  then  presents  the 
physical  signs  of  general  paralysis  together  with  the 
ordinary  mental  symptoms  of  melancholia.  But  the 
melancholic  symptoms  are  not  quite  ordinary  ;  they  are 
often  combined  with  an  element  of  grandiosity  in  excess 


GENERAL  PARALYSIS  251 

of  what  is  seen  in  ordinary  melancholia.  The  ordinary 
melancholic  believes  that  his  bowels  are  obstructed,  and 
that  he  has  had  no  motion  for  a  month  ;  the  melancholy 
general  paralytic  has  had  no  motion  for  thirty  years. 
The  ordinary  melancholic  has  a  ton  weight  resting  on 
his  body  ;  the  melancholy  general  paralytic  is  crushed 
under  the  weight  of  the  whole  earth.  The  melancholia 
of  general  paralysis  may  be  ordinary  dysphoric  abase- 
ment or  may  be  of  the  resistive  type.  It  may  be  asso- 
ciated with  stupor,  and  it  may  be  attended  with  suicidal 
attempts,  though  these  latter  are  not  common  in  general 
paralysis.  In  the  melancholic  form  there  are  not  the 
remissions  and  periods  of  improvements  that  take  place 
in  the  classical  form,  or  if  they  occur,  they  are  much 
less  pronounced. 

4.  General  paralysis  of  the  fulminating  type  is  a  terrible 
malady.  Whereas  the  other  types  of  the  disease  begin 
with  acute  insanity,  this  type  begins  with  the  acutest 
form  of  insanity — acute  delirious  mania.  Whereas  the 
other  types  pass  through  the  various  stages  in  the  course 
of  two  or  three  years  ere  they  terminate  in  death  from 
exhaustion,  the  fulminating  cases  run  their  course  in 
six  months,  in  four  or  three  months,  or  even  less.  The 
symptoms  are  those  of  the  classical  form,  but  they  are 
much  more  acute,  and  the  course  of  the  disease  is  very 
much  more  rapid. 

5.  The  circular  type  of  general  paralysis  is  rare.  It 
begins  in  the  ordinary  way  with  an  outbreak  of  sub- 
acute, culminating  in  acute,  insanity,  with  the  exalta- 
tion, braggadocio,  extravagance,  and  immorality  of  the 
classical  form.  After  a  few  months,  the  acute  symptoms 
subside,  as  they  usually  do  in  the  classical  form ;  but 
instead  of  the  relapse  that  takes  place  in  the  other  types 
of  general  paralysis,  the  patient  continues  to  improve 


252  A  TEXT-BOOK  OF  INSANITY 

until  he  is  practically  well,  and  it  is  thought  that  the 
diagnosis  was  wrong,  and  that  the  case  was  not  one  of 
general  paralysis  at  all.  After  a  few  months  of  sanity, 
the  patient  begins  to  be  depressed,  and  gradually  sinks 
into  profound  melancholia,  for  which  he  is  again  sent 
to  an  asylum,  and  from  which  he  again  recovers  and 
returns  to  active  life.  Then,  after  an  interval,  occurs  a 
new  outbreak  of  acute  mania,  and  the  circle  is  complete. 
The  circle  may  be  renewed  more  than  once  before  the 
physical  signs  exhibit  themselves,  and  the  case  then 
follows  the  usual  course  of  the  classical  type  of  general 
paralysis. 

6.  The  spinal  type. — General  paralysis  always  in- 
volves the  spinal  cord  sooner  or  later  ;  spinal  paralyses 
are  present  during  life,  and  spinal-cord  degeneration 
is  found  after  death.  In  the  ordinary  types,  the  brain 
is  affected  first  and  most ;  and  symptoms  due  to  disease 
of  the  spinal  cord  appear  late  in  the  course  of  the 
disease,  when  the  patient  is  already  a  wreck,  and  con- 
sequently do  not  attract  much  attention.  But  there 
are  cases  in  which  the  spinal  cord  is  first  attacked,  and 
the  malady  begins  as  tabes  or  as  spastic  paraplegia, 
upon  which  the  mental  and  other  symptoms  of  general 
paralysis  are  subsequently  grafted.  The  brain  and 
spinal  cord  form  one  continuous  organ,  and  a  morbid 
process  in  one  easily  spreads  to  the  other.  The  wonder 
is  that  tabes  and  general  paralysis  are  not  more  often 
associated. 

In  addition  to  the  six  forms  described,  general  paralysis 
exhibits  certain  peculiarities  when  it  occurs  in  women 
and  in  the  young. 

The  disease  is  less  frequent  in  women  than  in  men,  in 
the  proportion  of  less  than  one  to  five.  The  symptoms 
in  women  are  less  aggravated,  less  pronounced.     All 


GENERAL  PARALYSIS  253 

the  manifestations  are  milder.  The  type  is  usually  the 
elemented,  but  unlike  the  demented  type  in  men,  the 
course  of  the  malady  is  prolonged.  It  is  more  "  chronic  " 
in  character  than  it  is  in  men.  It  usually  sets  in  earlier 
in  life — nearer  thirty  than  forty, — and  the  physical 
symptoms  are  less  pronounced.  The  tremor,  the  articu- 
latory  defect,  the  involvement  of  pupils,  appear  later 
and  are  less  pronounced,  and  fits  are  less  frequent. 

In  children  also,  the  symptoms  and  the  course  of  the 
disease  are  sub-acute,  and  the  general  character  of 
the  malady  is  similar  to  that  in  women.  It  is  always 
associated  with  hereditary  syphilis. 

Physical  Signs. — These  are  of  extreme  importance, 
for  until  they  are  recognised  the  diagnosis  cannot  be 
made.  The  earliest  are  the  pupillary  changes.  Next 
come  defects  in  articulation ;  then  the  manual  move- 
ments, and  especially  the  handwriting,  are  affected  ; 
and  lastly  the  gait  deteriorates.  This  is  the  usual 
course,  but,  as  already  noted,  there  are  cases  in  which 
tabetic  symptoms  precede  the  mental  changes  by  months 
or  even  years. 

The  pupils  are  usually  unequal,  and  often  deviate 
from  circularity  and  become  oval  or  irregular  in  outline, 
and  they  fail  to  react  to  light,  or  in  accommodation,  or 
both.  In  ninety-nine  cases  out  of  a  hundred,  when 
unresponsive  pupils  co- exist  with  any  form  of  mental 
disorder,  the  case  is  one  of  general  paralysis.  As  far  as 
my  experience  goes,  the  pupillary  symptoms  are  not 
only  the  earliest  of  the  physical  signs,  but  they  are 
never  absent  in  commencing  general  paralysis.  Hence 
their  extreme  importance. 

The  articulatory  defect  comes  later,  and  is  highly 
characteristic.  It  is  exactly  the  same  as  that  of  a 
drunken  man.    The  speech  is  "  thick."    The  words  are 


254  A  TEXT-BOOK  OF  INSANITY 

clipped  and  run  together.  The  patient  often  speaks 
with  extreme  deliberation,  so  as  to  overcome  the  defect, 
of  which  he  is  conscious  ;  but  if  he  speaks  at  all  quickly, 
the  words  are  blurred  and  fused  together,  and  syllables 
are  omitted.  The  labials  and  dentals  are  first  affected  ; 
and  when  the  disease  is  further  advanced,  the  voice 
itself  becomes  involved  and  assumes  a  very  character- 
istic peculiarity.  It  becomes  monotonous.  Cadence  is 
lost ;  and  in  addition  there  is  often  a  peculiar  bleat, 
w^hich  can  always  be  recognised  after  it  has  once  been 
heard. 

The  face  is  remarkably  expressionless.  It  looks  puffy, 
and  the  normal  lines  and  folds  fill  up  and  disappear. 
The  cheeks  and  alw  nasi  are  often  shiny  with  grease,  and 
when  the  patient  speaks,  there  is  tremor,  not  only  of 
the  lips  and  of  the  tongue,  but  of  the  muscles  of  the 
cheeks  as  well. 

The  peculiarities  of  the  handwriting  have  already 
been  described.  Other  movements  of  the  hands  are 
often  defective.  The  patient  has  difficulty  with  his 
buttons,  and  cannot  pick  up  a  pin  from  a  plate  or 
other  smooth  surface. 

The  gait  does  not  become  defective  until  the  later 
stages  of  the  disease,  and  then  the  defect  is  not  very 
definite.  It  is  not  ataxic ;  it  is  not  a  reel ;  it  is  a 
general  inefficiency  which  is  scarcely  describable  other- 
wise. The  patient  walks  slowly,  turns  with  difficulty, 
and  is  apt  to  fall ;  but  there  is  no  localised  or  differen- 
tial paralysis.  It  is  a  generally  diffused  weakness  and 
incompetency. 

The  knee-jerks  are  usually  exaggerated  in  the  early 
stage  of  the  malady.  Subsequently  they  may  dis- 
appear and  reappear,  and  may  be  different  in  the  two 
sides. 


GENERAL  PARALYSIS  255 

Stages  and  Fits. — General  paralysis  is  a  progressive 
disease,  and  it  is  usually  described  as  marked  off  into 
three  stages,  the  first  extending  from  the  outbreak  of 
the  disease  until  the  first  fit ;  the  second  from  the  first 
fit  till  the  patient  becomes  bedridden ;  and  the  third 
the  bedridden  stage.  It  is  not  always  possible  to  mark 
these  distinctions,  nor  are  they  very  important.  But 
the  occurrence  of  the  fits  is  a  very  important  incident 
in  the  progress  of  the  malady. 

As  already  stated,  the  disease  may  begin  with  a  fit ; 
and  whether  it  does  so  or  no,  fits,  or  sudden  exacerba- 
tions allied  to  fits,  invariably  occur  in  the  course  of  the 
disease,  usually  beginning  about  midway  in  its  duration. 
In  different  cases  the  fits  are  very  different  in  character, 
but  in  the  same  case  the  fits  usually  are  closely  ahke. 
In  the  classical  type  of  the  disease,  the  fit  is  a  universal 
convulsion,  indistinguishable  from  those  of  epilepsy.  It 
begins  less  suddenly,  it  is  true,  than  epileptic  paroxysms 
usually  begin,  but  in  other  features  it  is  the  same.  The 
head  and  eyes  deviate  to  one  side,  the  spasm  becomes 
universal,  may  be  accompanied  by  evacuation  of  the 
bowels  and  bladder,  and  is  followed  by  a  period  of  coma. 
Fits  of  this  kind  may  succeed  one  another  rapidly,  so 
that  the  patient  passes  into  the  status  ejnlepticiis,  which 
is  far  more  common  in  general  paralysis  than  in  idio- 
pathic epilepsy ;  and  in  this  condition  a  certain  pro- 
portion of  general  paralytics  die. 

Very  commonly  the  fit  is  not  of  this  definite  character. 
Often  it  is  ''  apoplectiform,"  but,  in  this  case  again,  it 
rarely  has  the  very  rapid  onset  of  haemorrhagic  apoplexy. 
The  patient  becomes  duller  and  duller,  more  and  more 
stupid,  until  in  the  course  of  an  hour,  or  two  or  three 
hours,  he  is  comatose.  The  coma  is  not  usually  deep — 
rarely  so  deep  as  to  be  stertorous — and  often  it  is  found 


256  A  TEXT-BOOK  OF  INSANITY 

to  be  combined  with  rigid  deviation  of  head  and  eyes  to 
one  side,  so  that  it  partakes  of  the  nature  of  epilepsy. 

In  very  many  cases,  the  character  of  the  fit  is  less 
definite  than  this.  There  is  no  convulsion,  nor  is  there 
actual  coma,  but  the  patient  becomes  for  a  few  hours 
unusually  dull,  lethargic,  and  stupid.  He  lies  about ; 
he  does  not  answer,  or  he  answers  slowly  and  at  random  ; 
he  cannot  be  got  to  take  his  food  ;  he  seems  dazed  ;  he 
is  muscularly  weak  and  incapable  of  exertion ;  and 
when  this  condition  passes  of!,  he  is  found  to  have  under- 
gone the  deterioration  which,  as  will  be  presently  noticed, 
invariably  follows  the  fits  of  general  paralysis.  These 
attacks  are  sometimes  called  "  congestive  " — it  is  hard 
to  say  wh}^. 

At  the  stage  of  the  disease  at  which  fits  are  customary, 
there  sometimes  occur  causeless  attacks  of  bilious  vomit- 
ing, or  of  profuse  diarrhoea,  which  are  sometimes  followed 
by  fits,  and  sometimes  seem  to  take  the  place  of  fits,  or 
to  be  a  variety  of  them.  In  yet  other  cases,  the  fit  is 
replaced  by  a  local  paralysis,  or  by  a  general  loss  of 
power,  which,  by  its  sudden  or  rapid  onset  and  its 
gradual  recovery,  exhibits  its  community  of  nature  with 
the  more  easily  recognised  fit. 

It  is  sometimes  said  that  fits  do  not  occur  in  all  cases 
of  general  paralysis,  and  if  by  a  fit  is  meant  an  epileptoid 
or  apoplectiform  seizure,  this  is  true  ;  but  I  have  never 
seen  a  case  of  general  paralysis  in  which  periodical 
crises  of  some  kind  have  not  occurred  ;  and  if  we  include, 
as  I  think  we  should,  all  periodical  crises  of  every  kind 
under  the  term  ''fit,"  then  I  think  there  is  no  case  of 
general  paralysis  in  which  fits  do  not  occur. 

Whatever  the  nature  of  the  crisis  or  fit,  it  has  a  very 
marked  effect  upon  the  condition  of  the  patient.  When 
he  emerges  from  it,  he  is  found  to  be  greatly  deteriorated. 


GENERAL  PARALYSIS  257 

His  delusions  are,  perhaps,  less  prominent,  but  this  is 
because  he  is  too  stupid  to  entertain  them.  He  is  much 
weaker  in  body,  and  he  is  much  more  demented  in  mind. 
As  the  days  and  weeks  pass  by,  he  gradually  improves. 
He  climbs  the  hill  again  ;  he  recovers  a  great  part  of 
his  mental  and  bodily  aptitude,  but  invariably,  before 
he  has  completely  regained  the  ground  that  he  lost  by 
the  fit,  he  has  another  fit ;  and  when  he  emerges  from 
this,  he  is  found  to  be  on  a  lower  level  of  capacity,  both 
bodily  and  mental,  than  he  was  after  the  previous  fit. 
Again  he  climbs  the  hill.  Again,  after  the  lapse  of  weeks, 
or  it  may  even  be  months,  he  regains  a  great  deal  of  his 
lost  ground,  but  he  never  regains  it  all.  Invariably, 
before  he  has  attained  to  the  condition  that  he  reached 
after  the  first  fit,  a  third  occurs,  which  reduces  him  to 
a  still  lower  depth,  and  so  the  malady  progresses,  each 
fit  leaving  behind  it  a  greater  wreck,  from  which  recovery 
is  less  complete. 

This  effect  of  the  fits  upon  the  course  of  the  disease 
is  an  instance  of  the  periodicity  which  is  discernible 
more  or  less  distinctly  in  the  course  of  every  case  of 
general  paralysis.  General  paralysis  has  been  called 
progressive  paralysis,  but  its  course  is  never  continuously 
progressive.  While  its  general  course  is  steadily  down- 
ward if  sufficient  intervals  are  taken,  yet,  when  minutely 
examined,  it  is  found  that  this  downward  progress  is 
not  continuous,  but  is  always  remittent,  a  rapid  or 
sudden  decline  being  followed  by  gradual  improvement, 
and  this  alternation  being  continued  throughout  the 
disease.  This  character  is  discernible  from  the  very 
first.  The  outbreak  of  the  malady  is,  as  we  have  seen, 
sudden  or  very  rapid,  and  is  followed  by  a  gradual 
recovery,  which  may  be  so  complete  that  the  patient 
is  able  to  return  to  his  business,  and  to  resume  his  place 


258  A  TEXT-BOOK  OF  INSANITY 

in  the  world  for  several  months ;  and  this  is  called  a 
complete  remission.  But  when  careful  observation  is 
made,  it  is  found  that  the  remission  is  not  complete, 
but  that  it  conforms  to  the  rule  by  which  the  recovery 
from  every  crisis  culminates  in  a  state,  which  is  never 
so  near  a  return  to  the  normal  as  the  pre-critical  state. 
In  these  "  complete  remissions  "  it  is  found  that  the 
character  of  the  patient  is  a  good  deal  deteriorated, 
and  that  his  intelHgence  is  less  keen.  He  goes  back 
to  his  work  and  his  family,  it  is  true,  but  he  can  no 
longer  do  his  work  capably,  and  his  family  remarks  a 
decided  change  in  his  disposition.  Thus  the  circular 
type  of  general  paralysis  is  no  departure  from  the  type 
of  the  malady,  but  merely  an  exaggeration  of  a  feature 
which  all  cases  present  in  some  degree. 

With  each  recurrence  of  the  crisis,  the  patient  be- 
comes more  and  more  demented,  and  more  and  more 
paralytic.  At  length  he  becomes  incapable  even  of 
sitting  up,  and  is  confined  entirely  to  bed  ;  and  at  the 
same  time  lapses  of  the  control  of  his  bladder  and 
bowels,  which  have  been  occasional  since  the  crises 
began,  now  become  habitual.  The  patient  ceases  to  have 
the  character  of  an  intelligent  being.  He  lies  in  bed 
in  the  extreme  stage  of  dementia,  his  arms  crossed,  his 
legs  drawn  up,  all  his  limbs  gradually  becoming  more 
and  more  rigidly  contracted.  He  passes  his  urine  and 
motions  under  him.  He  is  incapable  of  conveying  food 
to  his  mouth  or  of  brushing  away  the  flies  that  crawl 
over  his  face  and  into  his  open  m-outh.  It  is  with  the 
greatest  difficulty  that  he  is  saved  from  getting  bed- 
sores, and  at  length  he  dies,  either  in  a  fit,  or  in  coma, 
or  from  diarrhoea,  or  pneumonia,  or  some  other  disease 
of  exhaustion.  This  bedridden  condition  is  called  the 
third  stage  of  the  disease. 


GENERAL  PARALYSIS  259 

The  general  bodily  condition  presents  characteristic 
peculiarities  in  the  three  stages  of  the  disease.  In 
the  first,  the  maniacal  stage,  the  patient  is  usually 
remarkably  "fit."  He  is  in  fine  "  condition."  He 
is  muscularly  strong,  and  he  is  wanting  in  superfluous 
fat.  His  condition  is  much  as  if  he  had  been  well  trained 
for  some  athletic  contest.  In  the  second  stage,  as  he 
becomes  stupid  he  gets  fat.  The  lines  on  his  face  fill  out 
and  are  obliterated,  and  his  face  becomes  more  greasy, 
pulpy-looking,  and  expressionless.  In  the  last  stage, 
he  emaciates,  and  the  emaciation  is  often  extreme. 

A  very  remarkable  and  very  unfortunate  nutritive 
anomaly,  that  may  take  place  at  any  time  after  the 
first  stage  of  general  paralysis,  is  a  change  in  the  struc- 
ture of  the  bones,  by  which  they  become  unusually, 
and  in  some  cases  surprisingly,  brittle.  This  change  is 
so  great  in  some  cases  that  a  rib  can  be  easily  broken 
with  a  thumb  and  finger,  and  as  general  paralytics 
become  very  helpless,  and  often  at  the  same  time  very 
restless  and  apt  to  fall  about,  the  brittleness  of  the  bones 
becomes  a  source  of  great  danger.  A  certain  number  of 
general  paralytics  die  every  year  from  pneumonia 
following  fractured  ribs,  or  from  shock  and  exhaustion 
following  fracture  of  other  bones. 

Diagnosis. — When  once  the  physical  signs  are 
decided,  there  is  no  difficulty  whatever  in  diagnosing 
general  paralysis.  The  defect  of  articulation  is  patho- 
gnomonic, and  the  pupillary  signs,  when  conjoined  with 
mental  disorder  of  any  kind,  are  equally  so.  But  before 
the  physical  signs  are  established,  the  difficulty  of 
deciding  whether  a  case  is  or  is  not  one  of  general 
paralysis  may  be  very  great — may,  indeed,  be  insuper- 
able. Cases  not  seldom  occur  in  which  a  diagnosis  is 
for   the    time    impossible,    and   we    must    wait    the 


260  A  TEXT-BOOK  OF  INSANITY 

further  development  of  the  disease  before  giving  an 
opinion. 

Generally,  any  rapid  or  sudden  outbreak  of  insanity, 
of  any  form,  in  a  middle-aged  man,  in  whose  family 
there  is  no  history  of  insanity,  should  put  us  on  our 
guard,  and  lead  us  to  suspect  general  paralysis.  Even 
a  definite  family  history  of  insanity  does  not  exclude 
general  paralysis,  but  it  is  much  more  frequent  in  men 
with  a  sound  family  constitution.  General  paralysis 
sometimes  begins  with  a  fit,  and  the  fits  are  very  varied 
in  character ;  hence  any  cerebral  crisis,  for  which  no 
adequate  cause  can  be  found,  should  raise  a  suspicion 
of  general  paralysis  when  it  occurs  in  middle  age. 

Acute  mania  with  grandiose  delusions  and  the 
scattering  of  cheques  for  millions,  even  when  occurring 
in  a  man  of  middle  age  and  a  fast  liver,  does  not  always 
mean  general  paralysis.  It  may  be  simple  acute  insanity 
and  may  recover.  But  if  any  of  the  physical  signs  of 
general  paralysis  are  present,  the  diagnosis  is  no  longer 
in  doubt. 

Dr.  Savage  lays  stress  upon  the  gain  of  weight  in 
the  melancholy  type  of  general  paralysis,  as  against 
the  loss  of  weight  or  the  continued  meagreness  of  the 
ordinary  melancholic.  This  gain  of  weight  is  a  very 
important  sign  if  the  pupillary  and  articulatory  defects 
are  absent,  but  usually,  by  the  time  the  patient  has 
entered  upon  the  fattening  stage,  these  motor  defects 
are  already  conspicuous. 

The  greatest  difficulty  in  the  diagnosis  of  general 
paralysis  is  in  deciding,  in  a  doubtful  case  with  a 
history  of  alcoholic  excess,  whether  the  disease  is 
general  paralysis  or  alcoholic  insanity.  The  difficulty 
is  the  greater,  since  general  paralytics  often  take  to 
drink  in  the  early  stage  of  the  malady,  and  often  have 


GENERAL  PARALYSIS  261 

habitually  indulged  too  freely  ;  and  it  is  the  greater 
since  alcohol  itself  produces  motor  disorder  allied  to 
that  of  general  paralysis.  The  main  reliance  must  be 
placed  on  the  pupillary  changes.  These  are  not  present 
in  alcoholic  insanity,  but  they  may  be  absent  also  in 
the  early  stage  of  general  paralysis.  The  history  of 
morning  vomiting  is  important.  There  are  only  two 
conditions  with  which  regular  morning  vomiting  is 
associated — pregnancy  and  alcoholism.  But  we  must 
be  careful  to  ascertain  that  the  vomiting  is  regular, 
and  is  not  a  sporadic  crisis.  The  general  paralytic 
sleeps  well,  though  his  sleep  is  short ;  the  alcoholic 
patient  sleeps  badly,  and  is  apt  to  suffer  from  terrifying 
dreams.  The  memory  does  not  present  in  general 
paralysis  the  characteristic  defect  in  recent  matters 
that  is  so  conspicuous  in  alcoholism.  The  defect  of 
gait  and  the  tremor  of  hands  in  the  two  maladies 
may  be  closely  alike,  and  in  alcoholism  the  articulation 
may  be  defective,  but  the  defect  is  not  of  the  same 
character. 

We  have  now  in  the  Wasserman  reaction,  in  the 
estimation  of  leucocytosis  in  the  cerebro-spinal  fluid, 
and  in  the  estimation  of  the  globulin  in  this  fluid,  tests 
of  the  presence  of  syphilis  that  are  of  the  utmost  value  ; 
and  since  general  paralysis  is  a  syphilitic  disease,  the 
determination  that  syphilis  is  present  in  a  doubtful  case 
of  mental  disease  goes  far  to  corroborate  a  diagnosis  of 
general  paralysis  ;  but  it  is  important  to  insist  that 
even  if  all  three  tests  yield  a  positive  result,  the  proof  of 
general  paralysis  is  not  conclusive.  Syphilis  is  a  very 
common  disease.  It  is  estimated  that  at  least  16  per 
cent,  of  the  population  of  this  country  are  infected  with 
it.  Mental  disease  of  other  kinds  than  general  paralysis 
is  by  no  means  rare  ;  and  the  doctrine  of  chances  showg 


262  A  TEXT-BOOK  OF  INSANITY 

that  there  must  be  a  small  number  of  cases  in  which 
both  maladies  coexist  in  the  same  case  independently, 
and  without  any  causal  nexus.  While,  therefore,  proof 
of  syphilis  goes  far  to  confirm  a  diagnosis  of  general 
paralysis  in  a  case  otherwise  doubtful,  it  is  not  con- 
clusive proof  of  general  paralysis.  I  have  seen  cases  in 
which  syphilis  coexisted  with  mental  disease  without 
being  the  cause  of  the  mental  disease,  and  such  cases 
cannot  be  very  rare. 

Prognosis. — General  paralysis  is  always  fatal,  and 
usually  is  rapidly  incapacitating.  Cases  are  not  very 
uncommon,  however,  in  which,  after  the  acute  attack 
of  insanity  which  marks  the  onset  of  the  disease,  the 
patient  recovers  sufficiently  to  return  to  his  family  and 
his  business  for  three,  six,  or  twelve  months,  or  even 
longer.  Sooner  or  later,  however,  the  malady  recurs, 
and  although  it  always  runs  a  remittent  course,  it  is  very 
rare  for  a  second  remission  to  be  so  complete  as  to  allow 
of  a  return  home.  The  average  course  of  the  disease 
is  about  three  years,  but  it  is  often  less  than  this,  and 
occasionally  it  is  prolonged  for  four  or  five  years.  The 
circular  type  is  that  of  longest  duration.  I  have  left 
this  paragraph  as  it  stood  in  the  first  edition,  but  I 
should  not  now  express  my  opinion  so  unconditionall}^ 
I  have  seen  cases  of  general  paralysis  that  have  lost  all 
signs  of  the  malady,  and  have  remained  well  for  years, 
until  I  lost  sight  of  them ;  and  I  have  seen  other  cases 
that  have  lasted  in  a  state  of  anoia,  not  very  deep,  for 
ten  and  fifteen  years. 

Treatment. — There  is  at  present  no  curative  treat- 
ment of  general  paralysis.  Seeing  how  intimately 
it  is  associated  with  syphilis,  it  is  natural  that  anti- 
syphilitic  remedies  should  have  been  extensively  tried, 
but  they  h^ve  never  been  found  of  the  least  use, 


GENEEAL  PARALYSIS  263 

Removal  to  an  institution  is  always  necessary.  In  no 
class  of  cases  do  we  witness  outbreaks  of  such  frantic 
violence  as  in  general  paralysis,  and,  as  they  take  place 
without  any  warning,  and  in  cases  that  have  previously 
been  quiet  and  tractable,  it  is  necessary  that  the  patient 
should  be  in  a  place  where  a  sufficient  stai!  is  available 
at  a  moment's  notice  to  deal  with  him  in  his  outbreak. 
For  the  rest,  treatment  must  be  of  symptoms,  and  it 
is  important  to  remember  that  general  paralytics  are 
very  amenable  to  the  action  of  drugs,  and  that  their 
allowance  of  tobacco  should  be  very  limited,  for  it  is 
very  apt  to  prostrate  them.  Sulphonal  is  the  best 
calmative  of  excitement,  and  paraldehyde  the  best 
hypnotic ;  but  the  former  easily  produces  a  great 
effect  upon  the  gait  by  its  paretic  effect  on  the  muscles. 
Trephining  has  been  tried,  to  diminish  an  imaginary 
intra  -  cranial  pressure,  but  without  any  beneficial 
effect ;  and  the  same  may  be  said  of  paracentesis  of 
the  spinal  canal.  Blistering  of  the  scalp  and  setons 
have  been  tried,  but  with  no  appreciable  beneficial 
effect.  In  the  second  stage  of  the  disease  the  patient 
becomes  extremely  voracious,  and  is  apt  to  choke 
himself  if  allowed  to  feed  himself.  His  food  must 
be  cut  up,  and  no  implement  larger  than  a  teaspoon 
allowed,  and  if  necessary  he  must  be  fed.  The  brittle- 
ness  of  the  bones  is  a  source  of  great  anxiety ;  and 
every  care  must  be  taken  to  prevent  the  patient  falling 
about,  or  getting  into  quarrels  with  other  patients.  In 
the  final  stage,  the  prevention  of  bedsores  must  be 
managed  secundein  artem,  and  the  status  epilepticus 
treated  in  the  usual  way  with  rectal  injections  of  chloral. 
Since  the  first  edition  of  this  book  was  published,  the 
trifonema  faUidum  has  been  found  in  the  brains  of 
general  paralytics,  and  by  the  discovery  some  of  the 


264  A  TEXT-BOOK  OF  INSANITY 

mystery  that  enveloped  the  pathology  of  general 
paralysis  has  been  dispersed.  Since  it  has  been  recog- 
nised that  general  paralysis  and  tabes  are  manifesta- 
tions of  syphilis,  the  great  difficulty  has  been  to  account, 
not  so  much  for  the  appearance  of  these  diseases  as  for 
their  non-appearance  for  so  many  years.  They  occur 
neither  in  the  primary,  in  the  secondary,  nor  in  the 
tertiary  stages  of  syphilis.  They  are  post-tertiary  in 
their  occurrence,  and  the  remedy,  iodide  of  potassium, 
that  is  so  effectual  in  tertiary  syphilis,  has  no  effect  at 
all  on  these  diseases,  which  have  therefore  been  called 
para-syphilitic,  and  have  been  conjectured  to  be  due, 
not  directly  to  the  triponema,  but  to  some  toxin  produced 
by  it.  Why  tabo-paralysis  is  so  late  an  occurrence  in 
syphilis  is  still  unexplained.  It  might  be  conjectured 
that  the  brain  and  cord  were  too  remote  and  inaccessible 
to  the  triponemce  were  it  not  that  gumma  of  the  brain 
and  cerebral  nerves  is  not  infrequent  in  the  tertiary 
stage  of  syphilis ;  but  some  inaccessibility  there 
certainly  is  in  these  organs,  for  the  impotence  of 
mercury  and  the  iodides  to  relieve  tabo-paralysis 
certainly  does  seem  to  depend  upon  the  difficulty  they 
have  in  penetrating  to  the  seat  of  the  micro-organism. 
This  being  so,  it  would  appear  that  a  remedy  directly 
applied  to  the  seat  of  the  disease  might  be  expected  to 
be  more  efficacious  ;  and  we  have  now  in  our  hands,  in 
salvarsan  and  neo-salvarsan,  microbicides  far  more 
effectual  than  the  iodides.  Attempts  have  therefore 
been  made  to  treat  tabes  by  direct  injections  of  sal- 
varsan and  neo-salvarsan  into  the  spinal  theca,  and 
general  paralysis  both  by  such  injections  and  by 
injections,  through  trephine  holes  in  the  skull,  into 
the  membranes  of  the  brain  and  the  cerebral  substance. 
This  mode  of  treatment  is  at  present  in  an  early  stage, 


GENERAL  PARALYSIS  265 

and  the  cases  in  which  it  has  been  tried  are  compara- 
tively few  ;  but  of  them  few  have  been  thus  treated 
without  some  improvement,  and  in  some  the  improve- 
ment has  been  great,  so  much  that  patients  with 
exorbitant  and  extravagant  delusions  have  so  far 
recovered  that  they  have  returned  to  business  and 
transacted  it  capably.  There  is  no  doubt  that  it  is  in 
this  manner  that  the  treatment  of  general  paralysis  will 
be  conducted  in  future. 

The  PatJwlogical  Anatomy  of  general  paralysis  is  very 
characteristic.  There  is,  it  is  true,  no  single  change 
which  may  not  be  found  in  other  maladies,  but  there 
is  no  other  malady  in  which  the  same  combination  of 
changes  is  found. 

The  skull  is  usually  thick  and  heavy ;  the  dura 
mater,  too,  is  usually  thickened  and  adherent  to  the 
skull.  Sometimes  a  meningeal  haemorrhage,  or  the 
remains  of  such  a  haemorrhage,  in  the  shape  of  cyst 
or  membrane,  is  found  between  the  dura  and  the 
arachnoid.  The  brain  is  manifestly  shrunken,  and 
in  consequence  the  sub-dural  and  sub-arachnoid  fluid 
is  copious,  so  that  the  arachnoid  and  pia  have  a 
thickened,  semi-opaque,  jelly-Hke  appearance.  When 
the  membrane  is  stripped  off,  it  is  found  to  be  strongly 
adherent  along  the  summits  of  the  convolutions  of  the 
frontal  lobe,  so  that  in  these  positions  a  portion  of  the 
brain  substance  is  torn  off  along  with  the  membrane, 
and  a  streak  is  left  in  the  middle  of  the  gyrus,  in  which 
the  brain  appears  as  if  it  had  been  nibbled  by  a 
mouse. 

The  brain  is  shrunken  in  all  its  dimensions  ;  the  gyri 
are  thin  and  the  sulci  wide,  this  change  being  most 
conspicuous  in  the  frontal  lobe,  and  diminishing 
backwards.     The  ventricles  are  large,  and  the  basal 


266  A  TEXT-BOOK  OF  INSANITY 

ganglia  small,  and  foci  of  softening  are  common  in 
various  parts  of  the  brain.  Histologically,  the  nerve 
elements  are  diminished  and  the  connective  tissue  is 
increased,  but,  as  is  evident  from  the  general  atrophy, 
the  former  process  is  greatly  in  excess  of  the  latter. 
Both  cells  and  nerve  fibres  suffer,  and  suffer  together, 
and  the  morbid  change  has  the  characters,  in  as  far 
as  they  are  distinct,  of  primary  rather  than  of  secondary 
degeneration.  The  cells  lose  the  definition  of  their 
outline,  and  not  only  of  their  external  contour,  but 
of  their  internal  organisation  also.  The  Nissl  bodies 
break  up  (chromatolysis),  the  nucleus  becomes  indistinct, 
its  outline  is  lost,  and  at  length  it  disappears.  The 
cell  loses  its  shape,  and  approaches  more  and  more  to 
the  shape  of  a  sphere,  by  an  apparent  retraction  of  the 
substance  that  is  prolonged  into  the  fibres,  and  by  the 
bulging  of  the  contour  between  the  origin  of  the  fibres. 
At  first  increased  in  size,  in  later  stages  it  shrinks, 
breaks  up  and  disappears,  leaving  a  pigmented  detritus 
which  is  subsequently  absorbed.  The  processes  partake 
in  the  destruction  of  the  cells.  As  the  cell-body  alters 
in  form,  the  processes,  from  being  manifest  prolonga- 
tions of  the  substance  of  the  cell,  appear  as  if  stuck 
into  it,  or  to  project  from  it  like  the  root  of  a 
turnip.  The  finer  ramifications  disappear,  the  main 
processes  shrink,  dwindle,  break  up  first  into  lengths 
and  then  into  granules,  which  are  absorbed  and 
disappear.  The  same  process  affects  the  association 
and  other  fibres. 

The  connective-tissue  element  in  the  brain  shows 
great  relative  increase,  owing  to  the  disappearance  of 
so  much  of  the  nerve  tissue  proper.  Whether  it  is 
upon  the  whole  increased  in  bulk  is  doubtful,  but 
certain   of   its   constituents   are   undoubtedly   larger, 


GENERAL  PARALYSIS  267 

more  prominent,  and  relatively,  if  not  absolutely, 
more  numerous.  The  glia  takes  the  stain  more 
deeply  than  in  the  normal  brain,  and  as  the  cells 
are  smaller  and  wider  apart,  from  the  absorption  of 
so  many,  it  constitutes,  in  any  one  section,  a  much 
larger  proportion  of  the  field.  The  glia  cells  appear 
to  be  more  numerous,  they  are  more  deeply  stained, 
they  are  larger,  and  their  visible  processes  are  more 
numerous  and  more  pronounced.  Where  the  nerve 
cells  are  most  affected,  the  spider  cells  are  very  numer- 
ous, and  exhibit  a  large  and  well-marked  process  passing 
to  the  wall  of  the  nearest  vessel,  where  it  ends  in  a  plate 
of  nucleated  protoplasm.  A  number  of  other  processes 
surround  and  envelop  the  degenerating  nerve  cell. 
As  the  nerve  cell  disappears,  the  body  of  the  spider 
cell  shrinks,  and  what  remains  of  it  at  last  is  a  network 
of  fibrils. 

The  blood  vessels  are  numerous,  large,  tortuous,  and 
dilated  at  intervals  along  their  course.  Their  coats 
are  thickened,  the  endothelial  nuclei  are  increased  in 
number,  and  around  the  vessel  are  groups  of  extrava- 
sated  leucocytes  mingled  with  hsematoidin  crystals. 
The  wall  of  the  vessel  exhibits  hyaline  or  fatty  change, 
the  perivascular  lymph  spaces  are  large,  and  contain 
masses  of  lymph-corpuscles  here  and  there. 

In  the  pia-arachnoid  the  vessels  are  unusually 
numerous  and  prominent,  and  the  whole  of  the  con- 
nective tissue  apparently  increased  in  amount,  and 
permeated  throughout  with  exudation  and  with 
nuclei. 

In  a  large  proportion  of  cases  changes  are  found  in 
the  spinal  cord  similar  to  those  in  the  brain.  The 
theca  is  similarly  thickened  and  adherent,  with  evidence 
ot  blood   extravasation   within   it,    and   occasionally 


268  A  TEXT-BOOK  OF  INSANITY 

grey  degeneration  of  the  columns  is  discernible  by  the 
naked  eye.  Microscopically,  the  changes  are  the  same 
as  are  found  in  the  brain,  and  are  most  marked  in  the 
posterior  columns,  less  in  the  lateral,  and  least  in  the 
anterior. 


CHAPTER   X 

SYMPTOMATIC  INSANITY  CONTINUED 

INSANITY   OF  GROSS   BRAIN  DISEASE 
TRAUMATIC  INSANITY 
INSANITY  OF  EPILEPSY 

INSANITY  OF  GROSS  BRAIN  DISEASE 

Meningitis  and  tumour  of  the  brain  do  not  often  exhibit 
active  insanity  as  a  symptom,  but  meningitis  if  diffused, 
and  intra-cranial  tumour  when  rapidly  increasing,  or 
when  Vory  large,  always  give  rise  to  coma,  and  coma  is, 
of  coarse,  insanity.  AVhen  coma  comes  on  slowly,  there 
is  a  precomatose  hebetude,  slowness  in  answering  and 
in  making  other  adjustments,  loss  of  power  to  think, 
with  general  mental  dullness  and  general  defect  of  con- 
duct, that  amount,  or  may  amount,  to  insanity,  though 
it  is  not  usually  so  styled,  nor  even  so  thought  of.  In  a 
few  cases,  however,  when  the  tumour  is  situated  in  the 
anterior  lobes,  an  unusual  place  for  tumour,  the  insanity 
is  of  an  active  kind,  and  is  what  anyone  would  recognise 
as  insanity.  One  case  has  been  published  in  which 
tumour  of  the  anterior  lobes  produced  symptoms  so 
closely  resembling  general  paralysis  as  to  be  mistaken 
for  this  disease. 

traumatic  insanity 
Insanity  that  can  be  definitely  traced  to  injury  to 
the  head  and  to  no  other  assignable  cause  is  rare,  but 

269 


270  A  TEXT-BOOK  OF  INSANITY 

cases  are  occasionally  seen.  It  is  indeed  frequent  for 
an  attack  of  insanity,  especially  in  the  young,  to  be 
assigned  by  the  relatives  of  the  patient  or  by  the  patient 
himself  to  a  blow  or  a  fall  on  the  head,  but  this  arises 
from  the  craving  of  the  human  mind  to  find  and  assign 
a  cause  for  every  event ;  and  when  critically  examined, 
the  traumatic  origin  of  the  insanity  rarely  appears  even 
plausibly  likely.  The  superabundant  activity  of  children 
and  young  people  perpetually  leads  to  accidents,  and 
in  them  falls  and  other  accidents  in  which  the  head  is 
struck  are  frequent  enough,  and  are  pretty  often  severe 
enough  to  lead  to  temporary  unconsciousness  ;  but  the 
very  frequency  of  such  accidents  compared  with  the 
relative  rarity  of  insanity  shows  that  they  are  not  a 
necessary  cause  ;  and  every  practitioner  of  experience 
must  have  met  with  cases  in  which  the  head  has  been 
severely  struck  and  prolonged  unconsciousness  has 
followed,  without  any  appreciable  damage  to  the  sanity 
of  the  patient ;  and  when  the  blow  on  the  head  is  not 
followed  by  any  sign  of  insanity  until  after  the  lapse  of 
years,  we  may  safely  dismiss  any  casual  agency  in  the 
blow. 

It  is  otherwise  when  insanity  follows,  as  it  sometimes 
does,  immediately  upon  a  serious  injury  to  the  brain. 
There  are  now  many  cases  on  record  of  penetrating  and 
lacerating  wounds  of  the  brain,  even  bullet  wounds, 
which  have  been  followed  by  recovery  as  far  as  bodily 
health  is  concerned ;  and  some  of  these  have  left  sur- 
prisingly little  effect  upon  the  sanity.  It  seems,  indeed, 
probable  that  in  many  persons  a  portion,  it  may  be  a 
considerable  portion,  of  the  cerebral  convolutions  is 
never  brought  into  use,  and  may  be  lost  without  appre- 
ciable defect.  It  is  difficult  otherwise  to  account  for  the 
enormous  differences  of  mental  capacity  in  persons 


INSANITY  OF  EPILEPSY  271 

whose  brains  are  approximately  equal  in  weight.  In 
other  cases,  however,  severe  injury  to  the  brain  is 
followed  by  defect  and  disorder  of  mind  of  various 
kinds  and  degrees,  and  in  some  of  these  cases  there  is 
insanity.  Since  the  injury  to  the  brain  may  be  of  very 
various  degree  and  in  very  various  locality,  there  are  no 
symptoms  characteristic  of  traumatic  insanity  except 
that,  unhke  other  kinds  of  insanity,  it  is  usually  accom- 
panied by  headache. 

INSANITY   OF  EPILEPSY 

Insanity  is  associated  wdth  epilepsy  in  many  ways. 
We  have  seen  that  idiocy  is  often  associated  vdth. 
epilepsy,  and  is  often  said  to  be  due  to  it  when  the 
epilepsy  begins  in  very  early  life.  But  we  have  no 
warrant  for  concluding  that  the  idiocy  is  the  result  of 
the  epilepsy,  which  is  itself  but  a  symptom  of  some 
grave  irregularity  in  the  mode  of  working  of  the  nerve 
elements.  It  is  more  likely  that  the  same  defect  in 
the  constitution  of  the  nervous  system,  which  displays 
itself  in  idiocy,  has  in  epilepsy  another  of  its  mani- 
festations. And  similarly,  when  it  is  said  that  long- 
continued  epilepsy  at  length  brings  about  insanity,  we 
are  arguing  post  hoc,  ergo  propter  hoc,  without  sufficient 
warrant.  Long-repeated  epilepsy  indicates  a  long-con- 
tinued morbid  condition  of  nerve  tissue,  and  increasing 
frequency  of  fits  indicates  increase  of  this  morbid 
condition,  whatever  it  may  be ;  and  the  insanity  that 
at  length  occurs  may  well  be  due  to  the  same  advance 
of  this  morbid  change  that  underlies  the  progress  of 
the  epilepsy.  So  that,  closely  as  epilepsy  and  insanity 
are  often  associated,  it  is  no  more  justifiable  to  regard 
the  epilepsy  as  the  cause  of  the  insanity,  than  to  regard 
the  insanity  as  the  cause  of  the  epileps}^  in  those  numerous 


272  A  TEXT-BOOK  OF  INSANITY 

cases  in  which  epileptic  convulsions  occur  in  the  final 
stage  of  insanity.  All  that  we  are  justified  in  saying  is 
that  insanity  and  epilepsy  are  very  closely  associated. 

Epileptics  may  be  permanently  insane,  or  their  in- 
sanity may  occur  only  in  connection  with  their  fits. 
The  permanently  insane  epileptics  are  those  whose 
epilepsy  has  begun  in  early  life,  and  who  have  never 
been  mentally  sound,  or  those  who,  after  lifelong 
epilepsy,  have  become  demented.  In  the  former,  the 
epileptic  idiots  and  imbeciles,  the  depth  or  severity  of 
the  imbecility  or  idiocy  bears  a  general  relation,  not  so 
much  to  the  severity  of  the  fits,  as  to  their  frequency  ; 
and  not  so  much  to  the  frequency  of  the  fits,  as  to  the 
earliness  in  life  at  which  they  began.  The  earlier  the 
epilepsy  begins,  and  the  more  frequent  the  fits,  the  deeper 
the  idiocy.  Epilepsy  (by  which  we  now  mean,  not  only 
the  periodic  convulsions,  but  the  tissue  change  which 
underlies  it)  which  does  not  make  its  appearance  until 
puberty  or  later  in  life,  does  not,  of  course,  affect  the 
mental  development  until  it  appears,  and  the  later  it 
appears,  the  more  complete  the  development  of  brain 
and  mind  before  they  begin  to  be  interfered  with. 

The  epileptic  idiot  is  not  different  from  other  idiots 
in  any  important  respect  except  the  fits,  bat  the  epileptic 
imbecile  differs  much  from  other  imbeciles.  He  is  usually 
more  robust  in  body.  He  is  taller,  bigger,  more  muscu- 
lar, more  energetic  than  other  imbeciles ;  he  is  often 
more  intelligent,  and  he  is  usually  more  industrious. 
Like  most  other  imbeciles,  he  is  heavy,  clumsy,  slow, 
and  awkward  in  his  movements  ;  and  withal  he  is 
irritable,  passionate,  and  quarrelsome.  Epileptics  are  a 
turbulent,  excitable  race,  prone  to  quarrelling  and 
violence. 

The  epileptic  dement  is  usually  very  demented.    His 


EPILEPTIC  INSANITY  273 

forehead  and  nose  are  often  scarred  from  the  results  of 
his  falls ;  his  aspect  is  heavy  and  dull ;  his  movements 
are  slow,  clumsy,  and  ineffectual.  Like  other  epileptics, 
he  is  Hable  to  outbreaks  of  impulsive  violence. 

Other  forms  of  chronic  insanity — fixed  delusion,  per- 
secutory delusion,  mania,  melancholia — are  not  often 
seen  in  epileptics  as  a  permanent  condition  in  the  inter- 
vals of  the  paroxysms.  The  form  of  the  insanity  is 
simple  defect  or  deprivation,  is  what  I  have  called 
anoia. 

In  connection  with  the  fits,  insanity  may  declare 
itself  before  the  paroxysm  or  after  it — pre-paroxysmal 
or  post-paroxysmal  insanity.  It  has  been  described 
also  as  replacing  the  fit,  as  an  outbreak  of  rage  or  acute 
mania  taking  place  at  the  time  the  fit  is  due,  and  un- 
accompanied by  any  fit.  It  is  probable  that  this  out- 
break is  usually  either  pre-paroxysmal  or  post-paroxys- 
mal, the  fit  having  been  slight  and  unnoticed ;  but  it 
seems  as  if  a  periodical  outbreak  does  sometimes  occur, 
at  a  time  and  of  a  character  that  is  regarded  as  pre- 
paroxysmal,  an  outbreak  which  rises  to  a  climax  and 
passes  away  without  the  actual  occurrence  of  a  fit. 

Pre-paroxysmal  Insanity. — Epileptic  fits  often  occur 
with  electric  suddenness,  and  with  no  preceding  or 
premonitory  symptoms  to  warn  us  of  what  is  about 
to  happen  ;  but  usually  there  is  a  warning,  and  the 
warnings  are  of  two  kinds.  The  first  kind  of  warning 
is  the  aura,  which  is  a  part  of  the  fit  itself,  and  which 
need  not  be  described  here,  as  it  is  fully  dealt  with 
in  works  on  general  medicine .  It  lasts  but  a  few  moments 
and  is  soon  superseded  by,  and  lost  in,  the  other  occur- 
rences of  the  fit.  The  second  kind  of  warning  is  of 
much  longer  duration.  It  consists  of  a  general  altera- 
tion of  disposition,  always  in  the  same  sense  in  the 


274  A  TEXT-BOOK  OF  INSANITY 

same  case,  which  enables  those  who  are  familiar  with 
the  patient  to  foretell  the  advent  of  a  fit  for  several 
hours,  and  often  for  several  days,  before  its  onset.  He 
becomes  more  and  more  irritable,  captious,  ill-tempered, 
and  apt  to  violence  ;  or  he  becomes  sullen,  morose,  silent, 
and  very  dangerous,  breaking  out  into  frantic  rage  if 
interfered  with  ;  or  he  gets  more  and  more  stupid, 
heavy,  dull,  and  lethargic,  until  he  may  sit  motionless 
for  the  greater  part  of  the  day,  and  be  scarcely  reusable 
to  take  his  meals  ;  or  he  is  gay,  excitable,  talkative, 
and  buoyant.  But  whatever  the  condition,  it  is  one 
foreign  to  his  usual  and  normal  state,  and  it  gradually 
becomes  more  and  more  pronounced  up  to  the  time 
when  the  fit  occurs.  Or,  as  has  already  been  noted,  it 
may  culminate  without  any  observable  fit,  in  some  out- 
break of  violence  which  is  characterised  by  suddenness, 
and  especially  by  extreme,  savage,  reckless  ferocity. 
Every  few  months  the  country  is  startled  by  some 
crime  of  horrible  violence,  in  which  the  victim  is  not 
merely  killed,  but  the  attack  is  pursued  and  continued 
after  life  is  extinct,  until  the  body  is  mutilated  almost 
out  of  the  semblance  of  humanity.  The  head  is  smashed 
and  battered  into  a  pulp,  or  the  body  and  Umbs  are 
hacked  and  hewed  with  blind  and  revolting  fury.  When 
the  matter  is  investigated,  it  is  found  that  either  there 
was  no  provocation  at  all,  or  that  what  provocation 
was  given  was  utterly  and  grotesquely  out  of  proportion 
to  the  terrible  vengeance  inflicted.  Then,  upon  still 
further  investigation,  it  is  found  either  that  the  criminal 
is  a  confirmed  epileptic,  or  more  commonly  that  he  has 
"  suffered  with  his  head  "  ;  that  he  has  been  "  very 
strange  in  his  manner  at  times  "  ;  that  other  members 
of  his  family  have  been  epileptic  ;  that  he  has  been 
subject  to  fainting  fits ;  that  he  has  done  odd  and  un- 


EPILEPTIC  INSANITY  275 

accountable  things ;  and,  in  short,  that  he  has  given 
evidence  by  which  we  can  conclude  that  he  has  suffered 
from  epilepsy,  and  that  the  crime  that  he  has  committed 
was  done  towards  the  end  of  the  pre-paroxysmal  stage 
of  epilepsy.  In  such  cases  there  is  not  usually  any 
actual  fit.  The  maniacal  violence  seems  to  take  the 
place  of  the  fit  and  to  bring  the  occurrence  under  the 
description  of  epilepsie  larvee  of  French  writers. 

Post-paroxysmal  Insanity. — When  the  alteration  of 
conduct  and  demeanour  of  the  prcr-paroxysmal  stage  is 
prolonged  and  is  well  marked ;  when  there  is  a  pro- 
longed warning  that  a  fit  is  coming  on  ;  w^hen  the  modi- 
fication of  character  gradually  and  continuously  in- 
creases up  to  the  time  of  the  fit ;  then,  when  the  fit 
does  occur,  it  entirely  clears  all  such  symptoms  away, 
and  the  patient  emerges  from  it  in  his  normal  condition 
— a  condition  which  may  not  be  one  of  wholly  sound 
mind,  but  which  is  normal  to  him.  The  time  immediately 
after  the  paroxysm  is  the  time  at  which  he  is  at  his  best. 
His  intellect  is  then  clearest,  his  temper  least  objection- 
able, his  conduct  most  orderly.  Moreover,  in  the  pre- 
paroxysmal  state,  in  which  he  is  in  some  degree  alienated, 
he  is  yet  as  fully  conscious  as  he  is  at  other  times.  Post- 
paroxysmal insanity  is  the  reverse  of  all  this.  The 
patient  as  a  rule  preserves  his  usual  conduct  and  de- 
meanour up  to  the  very  moment  of  the  fit.  There  is 
usually  no  w^arning  at  all  in  the  strict  sense,  though 
there  may  be  an  aura.  The  fit  is  often  very  slight — 
indeed,  elaborate  automatism  is  not  common  after 
severe  fits.  After  a  fit,  which  may  be  indicated  merely 
by  a  momentary  pallor,  or  an  instant  of  deviation  of 
the  eyes  and  head,  or  a  slight  sinking  at  the  knees,  or 
some  similarly  trivial  manifestation,  the  patient  enters 
upon  a  period  of  action,  which  is  distinguished  by 


276  A  TEXT-BOOK  OF  INSANITY 

certain  striking  peculiarities.  In  the  first  place,  of 
whatever  acts  he  then  does,  he  retains  not  the  slightest 
trace  of  recollection  afterwards  ;  and  hence  it  is  assumed 
that  when  he  does  them  he  is  wholly  unconscious,  an 
hypothesis  which  gains  corroboration  from  the  nature 
of  the  act.  This  is  usually  an  habitual  act.  It  is  some- 
thing which  the  patient  is  in  the  habit  of  doing,  and 
which  he  can  do  with  a  minimum  of  deliberation  and 
attention  ;  or,  rather,  it  is  the  caricature  of  some  such 
habitual  act — a  caricature  which  is  often  nullified  or 
vitiated  by  want  of  appreciation  of  the  circumstances 
under  which  it  is  done.  For  instance,  one  of  the  most 
frequent  of  these  automatic  acts  is  that  of  undressing  ; 
and  the  patient  will  start  to  undress  himself  wherever 
he  may  happen  to  be — in  the  street,  in  a  railway  train, 
at  a  dinner-party,  anywhere.  Or  he  will  make  water,  but 
instead  of  proceeding  to  a  urinal,  he  will  micturate  in  a 
corner  of  the  room  or  out  of  the  window,  or  he  will  use 
his  hat  or  his  beer- jug  for  a  chamber-pot.  Or  he  will 
wind  up  his  watch,  but  will  stick  the  key  in  anywhere 
it  will  go,  or  will  use  for  a  key  any  small  object  that 
comes  to  his  hand,  or  he  will  go  on  winding  until  he 
breaks  the  works.  Usually,  whatever  act  a  patient 
does  after  one  fit,  that  same  act  he  will  repeat  after 
every  fit,  but  this  is  subject  to  a  very  important  modifi- 
cation— viz.,  that  if  he  find  any  implement  in  his  hand 
or  handy,  he  will  be  very  apt  to  put  that  implement  to 
its  common  use,  or  to  some  caricature  of  its  common 
use.  If  he  happen  to  be  holding  a  pen,  he  will  make 
marks  on  the  surface  before  him.  If  he  happen  to 
be  holding  a  gun  or  pistol,  he  may  load  and  fire  it. 
If  he  happen  to  be  holding  a  knife,  he  may  cut  some- 
thing with  it.  Thus  it  happened  that  a  woman  was 
cutting  bread  and  butter  for  her  children's  tea  when 


EPILEPTIC  AUTOMATISM  277 

she  had  a  fit,  and  in  the  subsequent  automatism  she 
cut  the  arm  of  one  of  her  children,  so  that  it  died  ; 
and  in  a  similar  way  other  quasi-crimes  have  been 
committed.  Usually  the  period  of  automatism  after 
the  fit  lasts  for  a  few  minutes  only,  but  in  instances 
not  very  rare  it  is  prolonged  for  hours ;  and  there  are 
cases  in  which,  after  a  fit,  the  patient  lives,  as  it  were, 
a  new  life,  lasting  for  days,  weeks,  and  even  months. 
It  is  quite  a  usual  occurrence  for  a  patient  in  post- 
epileptic automatism  to  show  some  appreciation  of 
surrounding  circumstances.  I  have  seen  one  in  this 
condition  walk  for  several  hundred  yards,  getting  over 
a  stile  and  a  gate,  and  deviating  from  his  course  when 
shouted  at.  But  there  are  cases,  recorded  upon  un- 
impeachable authority,  in  which  the  patient  has  taken 
a  ticket,  has  travelled  a  long  distance,  put  up  at  hotels, 
bought,  sold,  and  transacted  other  business ;  and  at 
length,  after  days  or  weeks,  has  woke  up  to  a  recollection 
of  all  his  former  life  up  to  the  moment  of  the  fit,  after 
which  his  mind  was  an  utter  blank  as  to  every  experience 
that  he  had  undergone.  The  case  then  merges  into  one 
of  double  or  alternate  consciousness. 

In  treatment,  epileptic  insanity  requires  nothing  in 
addition  to  the  treatment  of  epilepsy  and  of  insanity. 
For  the  first,  the  main  reliance  is  upon  the  careful 
regulation  of  meat  in  the  diet,  and  the  prolonged  adminis- 
tration of  as  large  doses  of  bromides  as  the  patient  is 
able  to  endure.  In  the  dangerous  outbreaks,  the  ad- 
ministration of  hyoscin  will  be  found  very  effectual,  and 
the  status  e^pile'pticus  demands  treatment  secundem 
artem  by  rectal  injection  of  chloral  hydrate. 


CHAPTER  XI 

IDIOPATHIC  INSANITY 

CYCLICAL  INSANITY — FIXED  DELUSION — DEMENTIA 

Idiopathic  insanity  has  been  divided  first  into  that 
which  is  cyclical  and  that  which  is  not. 

cyclical  insanity 

Insanity,  like  every  other  organic  process,  exhibits 
periodicity.  In  every  case  of  insanity  that  is  at  all 
prolonged,  a  certain  rhythm  of  exacerbation  and 
subsidence  can  be  detected.  Epilepsy,  and  the  in- 
sanity associated  with  it,  are  conspicuous  instances  of 
periodicity,  more  or  less  regular.  In  general  paralysis, 
the  alternation  of  periods  of  excitement  and  of  calm 
is  usually  a  conspicuous  feature  of  the  disease.  In 
dysphoria,  the  depression  is  most  intense  in  the 
small  hours  of  the  morning.  In  mania,  the  excitement 
is  often  greatest  in  the  early  hours  of  the  night ;  and 
more  or  less  of  periodicity  of  the  most  various  length 
of  cycle  can  be  detected  in  all  cases  of  insanity.  There 
are  certain  cases  in  which  different  forms  of  insanity 
follow  one  another  in  regular  series,  which  is  repeated 
again  and  again,  and  to  this  variety  of  insanity  the 
names  folie  circulaire,  circular  insanity,  and  folie  a 
double  forme  have  been  given.  It  is  usually  described 
as  a  period  of  depression,  or  melancholia,  followed  by 

278 


CYCLICAL  INSANITY  279 

a  period  of  excitement  approaching,  or  attaining  to, 
acute  mania,  from  which  recovery  takes  place,  to  be 
followed  in  time  by  melancholia  again,  and  the  cycle  is 
then  repeated.  The  events  do  not  always  follow  this 
order,  however.  Sometimes  the  excitement  precedes 
the  period  of  depression.  Often  the  period  of  recovery 
is  not  one  of  complete  recovery,  but  one  of  mild 
dementia,  and  the  degree  of  dementia  may  be  so 
considerable  as  to  necessitate  the  permanent  detention 
of  the  patient  in  an  institution.  Then  the  case  becomes 
one  of  ordinary  dementia,  with  the  periodical  outbreaks 
of  excitement  which  are  so  common  in  dementia,  and 
with  periods  of  depression  of  only  slight  degree  sand- 
wiched between  them.  In  many  cases  the  patient 
recognises  the  nature  of  his  malady,  and,  when  he 
feels  it  coming  on,  he  voluntarily  seeks  the  protection 
of  an  institution,  from  which  he  returns,  when  the  attack 
is  over,  to  resume  the  business  of  life.  The  most  difficult 
and  unhappy  cases  are  those  in  which  the  degree  of  the 
excitement  is  just  insufficient  to  allow  of  the  certifica- 
tion of  the  patient,  and  he  remains  at  large  in  a  state 
of  sub-acute  mania,  dissipating  his  property  and 
bringing  scandal  upon  his  name,  until  the  period  of 
depression  sets  in,  to  plunge  him  into  agonies  of  remorse. 

There  is  a  variety  of  circular  insanity  in  which  the 
period  of  depression  is  replaced  by  a  period  of  stupor, 
usually  of  the  resistive  type,  and  to  this  variety  the 
name  of  Katatonia  has  been  given. 

The  symptoms  of  cyclical  insanity  at  any  given 
time  are  the  symptoms  of  the  particular  form  of  insanity 
that  the  patient  then  exhibits,  and  the  treatment 
corresponds.  The  prognosis  is  very  unhopeful.  The 
interval  of  lucidity  or  of  sanity  does  not  usually  become 
shorter,  but  the  recovery  therein  becomes  less  and  less 


280  A  TEXT-BOOK  OF  INSANITY 

complete,  until  a  definite  state  of  dementia  takes  its 
place  in  the  cycle. 

The  period  of  the  cycle  varies  much  in  difierent 
cases.  In  many  of  the  chronic  inmates  of  asylums  a 
periodicity  of  a  few  weeks  can  be  recognised  in  the 
outbreaks  of  excitement ;  but  in  what  would  be  called 
folie  circulaire  the  intervals  may  be  equal  or  unequal, 
the  rule  being  for  the  period  of  tranquillity  and  com- 
parative mental  health  to  be  considerably  longer 
than  those  of  depression  and  excitement,  which  are 
approximately  equal,  and  may  be  one,  two,  or  three 
months  or  more  in  duration. 

INSANITY  OF  FIXED  DELUSION 

The  three  kinds  of  insanity  that  are  next  to  be  de- 
scribed constitute  a  natural  group,  for  they  have  certain 
features  in  which  they  resemble  each  other  and  difier 
from  all  other  kinds  of  insanity.  They  all  belong  to  that 
larger  class  of  idiopathic  insanity  to  which  no  provoking 
cause  can  be  assigned,  and  they  are  distinguished  from 
the  other  sub-group  of  this  class  by  presenting,  in  a 
fixed  or  enduring  delusion,  a  predominant  outstanding 
feature  to  which  all  the  rest  of  the  insanity  can  be 
referred.  By  a  fixed  delusion  is  meant,  as  its  name 
implies,  a  delusion  that  endures  in  much  the  same  form 
for  years ;  that  is  never  absent  from  the  mind  of  the 
patient  except  when  his  attention  is  temporarily 
distracted  from  it ;  that  instantly  resumes  its  dominance 
when  the  attention  is  set  free,  and  that  even  when  the 
patient  is  attending  to  other  things  is  not  quite  absent 
from  his  mind,  but  is  merely  relegated  temporarily  to  a 
subordinate  position.  Of  such  delusions  there  are  three 
main  kinds,  which  characterise  respectively  the  three 
diseases  in  this  sub-group. 


PARANOIA  281 

PARANOIA 

In  the  first  of  these,  the  delusions  are  called  systema- 
tised,  not  a  very  happy  term,  but  one  that  is  fixed  in  use. 

By  a  systematised  delusion  is  meant  a  delusion  which, 
to  use  the  language  of  modern  psychology,  constitutes 
an  *'  apperceptive  system."  It  is  an  organised  body  of 
(false)  knowledge,  and  it  difiers  from  other  delusions  in 
the  fact  that  it  colours  the  whole  life  of  the  patient ;  it 
regulates  his  daily  conduct ;  it  provides  him  with  an 
explanation  of  all  his  experiences  that  are  otherwise 
inexplicable  ;  it  is  his  theory  of  the  cosmos. 

For  instance,  his  delusion  is  that  he  is  influenced  by 
telephones.  Whatever  he  does,  and  whatever  happens 
to  him  that  is  in  the  least  out  of  the  ordinary  course, 
is  due  to  the  telephones.  He  sees  a  pretty  flower,  and, 
forgetful  of  the  regulations  in  that  case  made  and 
provided,  he  plucks  it ;  then  he  remembers  the  rule 
against  picking  flowers.  It  was  the  telephone  that 
made  him  pick  it.  Intent  upon  the  beauty  of  some 
floral  gem,  he  trips  over  a  grass  verge ;  it  was  the 
telephone  that  made  him  trip.  He  sits  down  to  write, 
but  finds  his  mind  confused ;  telephones  again.  He 
plays  whist,  and  revokes  ;  the  telephone  made  him  do 
so.  He  plays  bilhards  and  loses  ;  the  telephone  kept 
his  balls  out  of  the  pockets  and  put  his  adversary's  in. 
His  nose  begins  to  bleed  ;  the  telephones  did  it.  He 
gets  annoyed  and  throws  his  book  across  the  room  ;  the 
telephone  prompted  him,  or  possessed  him  and  threw 
the  book  for  him.  He  sees  two  strangers  meet  and 
chat  on  the  opposite  side  of  the  street ;  the  telephone 
is  talking  to  them  about  him,  or  they  are  talking  to 
him  through  the  telephone,  or  the  telephone  is  mixed 
up  with  them  in  some  mysterious  way. 


282  A  TEXT-BOOK  OF  INSANITY 

The  precise  character  of  the  systematised  delusion  is 
very  widely  different  in  different  cases,  but  in  all  there 
are  several  features  in  common.  Through  every 
systematised  delusion  there  runs  the  thread  of  perse- 
cution, which  connects  them  all  together  in  a  single 
well-characterised  group.  Every  systematised  delusion 
is  a  delusion  of  persecution.  The  influence,  whatever 
it  be,  that  acts  upon  the  patient,  is  always  an  influence 
adverse  to  him.  Secondly,  the  delusion  is  a  fixed 
delusion ;  it  endures  without  material  change,  often 
without  appreciable  change,  for  years  and  years. 
Thirdly,  it  is  associated  more  closely  and  more  con- 
spicuously than  any  other  form  of  delusion  with  con- 
fusion of  thought.  Fourthly,  more  often  than  any  other 
delusions  it  is  associated  with  hallucination. 

The  character  of  the  delusion  is  very  various,  though, 
as  has  been  said,  the  idea  of  persecution  runs  through 
them  all.  The  persecutor  may  be  a  specific  individual, 
and  in  that  case  may  have  a  real  existence  or  be  wholly 
imaginary.  In  a  certain  case,  e.g.,  the  patient  was 
annoyed  by  a  man  whom  he  had  never  seen,  but  whose 
presence  he  felt,  whose  name  was  Girardot,  and  who 
haunted  the  lanes  and  fields  about  the  patient's  resi- 
dence, armed  with  an  apparatus  of  mirrors  and  lenses 
by  which  he  was  enabled  to  see  at  all  times  what  the 
patient  was  doing,  and  to  locate  him  so  accurately 
that  he  could  pour  upon  him  without  fail  a  stream  of 
electricity,  which  produced  baleful  effects.  Not  in- 
frequently the  persecutor  is  identified  as  the  super- 
intendent of  the  asylum,  or  the  governor  of  the  gaol,  in 
which  the  patient  has  been  detained,  and  who  still, 
by  his  emissaries,  torments  the  patient,  years  after  the 
latter  has  been  transferred  to  other  care.  They  haunt 
the  neighbourhood ;    they  are  under  the  floor,  in  the 


PARANOIA  283 

cellars  ;  they  are  in  rooms  above,  or  on  the  roof  ;  they 
are  in  adjoining  rooms  ;  every  mishap,  every  incon- 
venience, every  disappointment  that  happens  to  the 
patient  is  ordered  by  them.  Or  the  persecutors  are  not 
specifically  identified,  but  pervade  the  community. 
The  people  in  the  streets  talk  to  each  other  about  him  ; 
they  look  at  him  in  meaning  ways  ;  if  they  smile  or 
laugh,  it  is  in  contempt  or  derision  of  him  ;  if  he  catches 
scraps  of  their  conversation,  this  also  has  reference  to 
him.  He  sees  two  men  meet  who  are  total  strangers 
to  him ;  they  shake  hands,  they  smile,  and  ask  each 
other  how  they  do  ;  the  shake  of  the  hands  is  a  Masonic 
grip  by  which  each  recognises  that  the  other  is  in  the 
plot ;  the  smile  is  an  expression  of  triumph  that  they 
have  succeeded  in  their  nefarious  design  against  him  ; 
the  question  and  answer,  while  seemingly  innocent, 
really  refer  in  some  way  to  him,  and  means  that  he  is  a 
blasphemer,  a  murderer,  an  adulterer,  or  what  not. 
In  some  cases  the  delusion  is  of  bodily  disfigurement ; 
for  instance,  the  nose  is  too  large,  is  so  large  as  to 
attract  attention,  and  the  universal  topic  of  conversa- 
tion, wherever  the  patient  appears,  is  the  size  of  his  nose. 

Very  often  the  delusion  is  of  being  followed  about 
and  watched,  it  may  be  by  the  police,  but  more  often 
by  unofficial  watchers.  Sometimes  the  vigilant  enemy 
is  a  single  specific  individual,  sometimes  two  or  more, 
sometimes  a  number  of  unspecified  individuals. 

Perhaps  the  commonest  of  all  the  forms  of  perse- 
cutory delusion  is  that  of  being  acted  upon  by  some 
unseen  influence ;  and  usually  the  latest  conspicuous 
discovery  in  physics  is  pressed  into  the  service,  and 
becomes  the  prosecuting  agent.  In  the  early  part  of 
the  last  century,  paranoiacs  were  persecuted  by  steam- 
engines  ;    later,  the  telegraph  was  the  means  of  their 


284  A  TEXT-BOOK  OF  INSANITY 

persecution  ;  then,  as  successive  discoveries  were  made, 
electricity,  hypnotism,  mesmerism,  animal  magnetism, 
telephones,  the  Rontgen  rays,  and  wireless  telegraphy 
were  made  responsible  for  their  sufierings.  The 
majority  still  ascribe  their  persecution  to  electricity, 
and  the  "  electrics "  constitute  the  largest  class  of 
paranoiacs.  But  they  are  assiduous  readers  of  the 
newspapers,  for  they  see  in  the  daily  prints  references 
to  themselves  in  the  items  of  news  and  in  the  leading 
articles ;  and  whenever  a  new  physical  discovery  is 
announced,  it  is  appropriated  by  them  as  a  means  of 
persecution,  and  the  more  obscure  it  is  in  its  nature, 
the  less  they  are  able  to  understand  of  the  new  process, 
the  more  it  commends  itself  to  them  as  a  persecuting 
agent.  This  seems  to  be  the  ground  upon  which 
electricity  is  so  often  selected.  Sometimes,  however, 
nothing  sufficiently  mysterious  exists  among  the  known 
natural  agents,  and  then  a  new  agent  is  invented  to 
account  for  the  sufferings.  Dr.  ConoUy  Norman  gives 
an  instance  of  a  patient  who  ascribed  his  persecution 
to  a  ''  typhone,"  and  of  another  whose  thoughts  were 
"  read  by  a  hypophone  and  translated  into  logarithms." 
A  patient  complained  to  me  that  he  was  persecuted 
by  "  infernal  traces  mystery  "  ;  another  was  annoyed 
by  "  injury  stuff  like  smoke  "  ;  and  another  by  micro- 
scopical glasses. 

While  it  is  not  very  uncommon  for  the  centre  of  the 
persecution  to  be  some  bodily  peculiarity — the  large 
nose  or  the  deformed  mouth,  which  attracts  the  atten- 
tion of  bystanders,  and  sets  them  talking  about  it, 
and  nudging  each  other  as  the  patient  goes  about  the 
streets — it  is  more  common  for  the  mysterious  influence 
to  be  exerted  upon  the  mind.  Other  people  read  their 
thoughts,  or  think  their  thoughts,  or  put  thoughts  into 


PARANOIA  285 

their  minds,  or  deprive  them  of  the  power  of  thinking, 
or  say  or  do  things  through  them  which  they  would 
not  say  or  do  of  themselves. 

Delusions  of  persecution  are  always  associated  with 
confusion  of  mind.  No  doubt  with  all  delusions  there 
is  more  or  less  confusion,  or  the  delusion  would  not 
continue ;  but  in  no  case  is  the  confusion  of  mind  so 
conspicuous  and  complete  as  it  is  in  cases  of  paranoia. 
The  delusion  is  in  no  case  so  clearly  defined,  so  sharply 
cut,  so  definite  in  expression,  as  it  is  in  the  delusions, 
for  instance,  of  abasement  and  of  exaltation.  The 
confusion  is  often  conspicuous  in  the  very  statement 
of  the  delusion  itself,  as  in  the  case  of  the  man  who 
was  persecuted  by  "  infernal  traces  mystery,"  or  when  a 
man  is  referred  to  in  terms  which  he  cannot  repeat,  by 
persons  whom  he  has  never  seen,  under  circumstances 
that  he  cannot  identify ;  but  if  the  delusion  itself 
appears  to  be  definite,  as  when  the  persecution  is  the 
utterance  of  specific  expressions  by  a  specified  person,  a 
little  conversation,  a  little  questioning  of  the  patient, 
will  nearly  always  elicit  a  statement  which  is  a 
mere  farrago  of  nonsense,  an  unintelligible  jumble  of 
words. 

Hallucinations  are  more  constant  and  more  promi- 
nent in  paranoia  than  in  any  other  variety  of  insanity. 
They  may  be  referred  to  any  of  the  senses,  and  are  by 
far  most  frequently  auditory,  and  least  often  olfactory. 
Visual  hallucinations  rank  next  in  frequency  to  auditory, 
gustatory  come  next,  but  are  rare,  and  the  olfactory 
and  those  of  common  sensation  rarest  of  all. 

Auditory  hallucinations  are  the  most  frequent  of  all, 
and  are  of  serious  import  in  three  ways.  In  the  first 
place,  the  "  voices  "  are  often  minatory,  abusive,  and 
objurgatory,  and  when  this  is  the  case  they  may  lead 


286  A  TEXT-BOOK  OF  INSANITY 

the  patient  to  retaliate  with  violence  upon  some  inno- 
cent bystander  or  passer-by  to  whom  he  attributes 
them.  In  the  second  place,  the  "  voices  "  are  often 
mandatory  and  imperative,  or  persuasive  and  urgent. 
They  command  or  they  incite  the  patient  to  do  things, 
and  the  acts  thus  proposed  to  him  are  often  objection- 
able, criminal,  or  even  murderous  in  character.  They 
are  usually  resisted  and  repelled,  but  if  they  continue, 
as  they  usually  do,  for  a  long  time,  the  resolution  of 
the  unfortunate  patient  at  last  breaks  down,  and  he 
commits  the  act  to  which  he  has  so  long  been  urged. 
In  the  third  place,  the  existence  of  auditory  hallucina- 
tions gives  a  very  unfavourable  colour  to  the  prognosis 
of  any  case  in  which  they  are  well  established.  This  is 
true,  however,  in  increased  degree,  of  other  forms  of 
hallucination.  Auditory  hallucinations  are  occasionally 
heard  on  one  side  only.  Sometimes  the  voice  is  always 
the  same,  sometimes  two  or  more  voices  are  heard, 
and  in  some  cases  they  argue  with  one  another,  and 
in  that  case  one  may  abuse  and  the  other  defend  the 
patient.  The  sufierer  usually  recognises  completely  at 
first  the  unreal  character  of  the  voice,  and  that  it  is  not 
produced  by  any  external  agent ;  and  afterwards,  even 
although  he  may  attribute  the  voice  to  bystanders, 
there  is  evidently  some  quality  by  which  he  distinguishes 
it  from  the  voices  of  real  people,  for  he  always  speaks 
of  it  as  "  the  voice  "  and  "  the  voices."  Deafness  is,  of. 
course,  no  bar  to  the  occurrence  of  auditory  hallucina- 
tions. 

Visual  hallucinations  are  much  rarer,  upon  the  whole, 
than  auditory,  though  they  are  much  commoner  as 
epileptic  aurse,  which  stand  on  quite  a  different  footing 
from  the  hallucinations  of  paranoia.  These  are  usually 
quite  elaborate,  and  may  consist  of  faces  or  figures — - 


PARANOIA  287 

those  of  delirium  tremens  have  often  been  described — 
or  sometimes  they  consist  of  words  or  sentences, 
luminous  or  not,  standing  out  as  if  printed  upon  the 
surface  of  whatever  the  patient  is  looking  at.  In  such 
cases  the  words  are  usually  of  the  same  character  as  the 
"  voices  "  in  auditory  hallucination — that  is  to  say, 
they  are  blasphemous  or  objurgatory  or  obscene. 

Evil  tastes  and  smells  are  sometimes,  but  rarely, 
complained  of.  The  taste  is  always  disagreeable, 
usually  metallic,  and  the  smell  ofiensive.  One  patient 
complained  to  me  that  he  *'  smelt  blood." 

How  far  the  frequent  sexual  delusions  of  the  paranoiac 
are  dependent  upon  hallucinatory  common  sensation  it 
is  impossible  to  say,  but  if  they  are  so  dependent, 
hallucinations  of  this  class  would  be  among  the  most 
frequent,  for  nothing  is  more  common  than  for  female 
paranoiacs  to  complain  of  being  raped  and  outraged  in 
complex  and  horrible  ways,  and  for  male  paranoiacs  to 
complain  of  sodomy  and  various  sexual  tamperings 
being  practised  upon  them. 

The  conduct  of  the  paranoiac  is  dominated  by  his 
delusion.  In  this  is  the  marked  and  conspicuous 
difference  between  paranoia  and  mere  fixed  delusion. 
In  the  latter,  the  patient  goes  about  his  work  like  an 
ordinary  mortal,  and  refers  to  his  delusion  at  intervals 
only,  between  which  there  is  nothing  to  distinguish 
his  conduct  from  that  of  a  sane  person.  But  the  de- 
lusions of  the  paranoiac  dominate  his  whole  life.  They 
are  with  him  every  hour  and  every  minute  of  the  day. 
They  keep  him  from  his  work,  they  interfere  with  what- 
ever he  tries  to  do.  However  he  is  occupied,  he  feels 
the  electric  shocks,  he  hears  the  voices  abusing  him  or 
conspiring  against  him,  he  is  conscious  of  the  vapours 
pouring  upon  him,  and  under  these  circumstances  he 


288  A  TEXT-BOOK  OF  INSANITY 

cannot  work,  he  cannot  maintain  any  steady  employ- 
ment. If  we  watch  him,  we  see  him  twitch,  start,  and 
jump,  as  the  shocks  affect  him,  or  we  notice  his  expec- 
tant attitude ;  we  see  him  absorbed  in  contemplation 
of  his  visions,  or  we  hear  him  answer  and  expostulate 
with  his  hallucinatory  voices.  Another  thing  that  pre- 
vents him  from  pursuing  his  business  is  the  necessity 
of  avoiding  his  persecutors.  To  this  end,  he  eschews 
going  out  in  the  daytime ;  he  cannot  remain  long  in 
one  residence  ;  he  frequently  and  suddenly  changes  his 
lodging  ;  if  he  is  well-to-do,  he  travels  from  country  to 
country  to  escape  from  the  annoyances,  hoping  in  each 
to  find  more  efficient  police,  able  to  give  him  protection. 
But  the  most  important  character  of  the  conduct  in 
persecutory  delusion  is  the  tendency  to  violence  and 
to  homicide  that  so  often  exists.  The  continuance  of 
the  persecution,  the  futility  of  all  measures  taken  against 
it,  the  refusal  of  the  authorities  to  interfere,  the  general 
neglect  of,  and  disbelief  in,  his  trouble,  at  last  generate 
a  degree  of  exasperation  which  prompts,  it  may  be  to 
violence,  it  may  be  to  murder.  When  the  persecutor 
is  identified  with  any  specific  person,  the  violence  is, 
naturally,  directed  against  that  person ;  but  when,  as 
so  often  happens,  no  accessible  person  or  no  specific 
individual  is  identified  as  the  persecutor,  then  the 
violence  may  be  directed  against  anyone,  and  is  usually 
directed  against  some  person  in  a  prominent  position, 
the  avowed  motive  being  "  to  draw  attention  to  the 
case."  In  some  cases  the  hallucinatory  voices  prompt 
the  patient  to  commit  some  deed  of  violence ;  he 
resists  for  weeks  or  months,  but  at  last,  in  a  fit  of 
exasperation,  his  resistance  gives  way,  and  he  does 
what  he  is  told.  In  rare  cases,  the  violence  thus  insti- 
gated may  be  directed  against  himself  ;  but,  intolerable 


PARANOIA  289 

as  the  life  of  the  paranoiac  is  made  by  his  persecution, 
he  very  rarely  finds  refuge  in  suicide. 

The  bodily  state  of  the  paranoiac  offers  nothing 
remarkable.  There  is  no  doubt  that  they  do  suffer 
torments  from  abnormal  sensations  of  various  kinds, 
but  we  can  never  discover  any  justification  for  these 
sensations  in  an  altered  bodily  process. 

The  whole  frame  of  mind  of  the  paranoiac  usually 
differs  from  that  of  the  melanchohc.  The  melanchohc 
often  complains  of  persecution,  and  pities  himself  with 
deep  commiseration,  but  he  is  not  resentful.  Often  he 
regards  his  persecution  as  deserved,  and  when  he  does 
not,  he  tries  to  escape,  but  never  to  retaliate.  The 
paranoiac  is  almost  always  resentful,  and  is  incHned  to 
retaliate  and  avenge  himself.  Formerly  I  thought  the 
paranoiac  was  never  self- condemnatory,  but  I  have  now 
seen  cases  in  which  delusions  of  persecution  by  means 
of  a  plot,  delusions  unquestionably  paranoiac  in  charac- 
ter, have  been  associated  with  abasement,  with  con- 
viction of  personal  unworthiness  and  sin. 

Paranoia  is  sometimes  a  sequel  to  an  attack  of  acute 
insanity,  but  often  it  is  an  original  malady,  arising 
gradually  and  becoming  gradually  intensified  for  months 
or  years  before  it  is  recognised.  Usually  a  family  history 
of  insanity  can  be  traced,  but  this  is  far  from  invariable. 
It  is  an  incurable  and  irrecoverable  malady.  As  age 
advances,  the  prominence  of  the  delusion  subsides,  and 
in  rare  cases  the  patient  can  be  trusted  to  resume  his 
place  among  his  fellow-men,  but  such  cases  are  very 
few  indeed.  The  broad  general  rule  is  that  paranoia  is 
irrecoverable.  Curative  treatment  there  is  none.  AMien 
we  find  syphilis  among  the  antecedents  of  the  disease, 
the  syphilis  should  be  treated,  but  we  must  not  expect 
the  treatment  to  affect  the  insanity, 
u 


290  A  TEXT-BOOK  OF  INSANITY 

The  need  of  restraint  in  an  institution  is  more  im- 
perative in  paranoia  tlian  in  any  other  form  of  insanity, 
and  the  rule  is  stringent  that  no  paranoiac  should  be 
allowed  at  large.  If  he  is  so  allowed,  his  perpetration 
of  a  murder  is  merely  a  matter  of  time,  and  is  certain 
to  take  place  if  time  be  allowed.  Scarcely  a  week,  and 
never  a  month,  passes  in  which  the  newspapers  do  not 
report  a  murder  committed  by  a  person  sufiering  from 
this  form  of  insanity  and  one  who  obviously  ought  to 
have  been  placed  in  an  asylum  years  before. 


MEGALOMANIA.       SOMATIC  DELUSION 

These  two  kinds  of  insanity  may  be  taken  together 
They  are  both  idiopathic  insanities  that  occur  without 
assignable  cause,  and  both  are  distinguished  by  the 
predominating  feature  of  a  fixed  delusion.  In  megalo- 
mania the  delusion  is  a  delusion  of  exaltation,  in  somatic 
delusion  it  is  a  belief  in  some  alteration  or  infestation 
of  the  patient's  body.  There  are,  it  is  true,  patients 
who  entertain  delusions  that  their  minds  are  altered 
and  acted  upon  by  others,  but  these,  as  far  as  my 
experience  goes,  are  paranoiacs.  To  this  variety  of 
insanity  belong  practically  all  the  kings,  queens,  em- 
perors, and  millionaires  who  are  not  general  paralytics, 
and  to  this  also  belong  the  people  who  have  weasels, 
wolves,  or  crabs  in  the  stomach,  glass  legs,  no  backs 
to  their  heads,  whose  brains  have  been  taken  out,  and 
who  suffer  from  other  changes  of  the  personality. 

The  distinguishing  feature  of  the  insanity  is  that  the 
delusion  has  practically  no  effect  upon  conduct.  The 
kings  and  emperors  are  content  to  pass  their  lives  in 
the  most  menial  occupations,  scrubbing  floors  and 
carrying  coals ;    the  queens  and  duchesses  work  con- 


MEGALOMANIA.    SOMATIC  DELUSION    291 

tentedly  in  the  laundry ;  the  millionaires  see  nothing 
inconsistent  with  their  wealth  in  holding  a  horse  for 
a  copper,  or  begging  for  a  bit  of  tobacco.  What  in- 
capacity they  have  for  more  intelligent  employment — 
and  the  incapacity  is  often  considerable — they  owe  to 
their  dementia,  and  not  to  their  delusion.  The  delusion 
is  not  often  prominent.  It  does  not  absorb  much  of 
the  attention  of  the  patient.  He  does  not  obtrude  it, 
and  make  himself  a  nuisance  by  worrying  about  it  in 
season  and  out  of  season,  as  the  paranoiac  does.  He  is 
often  rather  reticent  about  it,  and  has  to  be  questioned 
and  cross-examined  before  he  will  confess  to  it ;  but 
once  started  on  the  subject,  he  is  usually  difficult  to 
stop.  In  any  case,  not  only  does  it  not  influence  his 
conduct,  but  it  does  not  much  affect  the  rest  of  his  mind. 
The  king  and  the  millionaire  do  not  appear  particularly 
elated  by  the  knowledge  of  their  exalted  position  or 
their  wealth.  The  man  whose  legs  are  of  glass,  or  whose 
stomach  is  tenanted  by  an  unbidden  guest,  does  not 
worry  about  his  crural  fragility  or  his  parasite.  The 
delusion  forms  a  small  and  unimportant  part  of  his 
mental  life,  and  he  pursues  the  tenour  of  his  way  with- 
out regarding  it.  A  large  number  of  the  inmates  of 
lunatic  asylums  exhibit  this  variety  of  insanity. 

The  bodily  state  exhibits  nothing  characteristic.  The 
malady  is  chronic,  unchanging,  and  irrecoverable. 
The  patients  remain  in  the  same  state  of  dementia  and 
delusion  for  the  rest  of  their  lives ;  liable,  like  other 
dements,  to  outbreaks  of  excitement  from  time  to  time  ; 
subject  to  the  common  ailments  of  humanity,  of  one 
of  which,  in  the  fulness  of  time,  they  die. 


292  A  TEXT-BOOK  OF  INSANITY 


DEMENTIA 

Dementia,  the  type  of  insanity,  is  always  of  the  form 
anoia.  Dementia,  the  disease,  is  always  of  the  type 
dementia.  It  would  be  better,  no  doubt,  if  we  could 
give  a  third  name  to  the  type,  and  keep  the  name 
dementia  for  the  disease.  The  application  of  the  same 
name  to  the  disease  and  the  type  is  confusing,  but 
there  need  be  no  confusion  if  we  remember  that  when 
the  type  constitutes  the  whole  of  the  correlated  dis- 
order from  which  the  patient  suffers,  the  type  is  co- 
extensive with  the  disease ;  but  when,  as  in  general 
paralysis,  the  type  dementia  is  only  part  of  the  corre- 
lated disorder,  it  is  a  type  only,  and  the  disease  is  more 
than  the  insanity. 

There  are  many  cases,  however,  in  which  dementia 
constitutes  a  disease  of  itself  and  is  correlated  with  no 
other  disorder,  and  in  these  cases  the  dementia  is  a 
kind  of  insanity. 

Clinically  we  may  classify  cases  of  dementia  accord- 
ing to  the  way  they  begin.  A  certain  number  of  cases 
of  acute  insanity  recover,  and  recover  to  all  appearance 
completely,  and  as  far  as  we  know  permanently.  The 
remainder  do  not  recover.  The  acuteness,  that  is  to 
say,  the  intensity,  of  the  symptoms  abates ;  the  active 
symptoms  disappear,  more  or  less  completely,  and  leave 
the  anoia,  which  has  existed  throughout  the  acute  stage, 
as  the  only  outstanding  feature  of  the  malady.  The 
case  then  becomes  clinically  a  case  of  dementia.  In  my 
opinion  almost  every  case  of  acute  insanity  that  recovers 
passes  through  a  stage  of  dementia  between  the  subsi- 
dence of  the  acute  symptoms  and  complete  restoration 
to  sanity.    As  a  rule,  we  are  so  relieved  and  so  thankful 


DEMENTIA  293 

when  the  actual  symptoms  subside  and  signs  of  recovery- 
appear  that  we  cease  to  observe,  or  cease  to  interpret 
our  observations  correctly.  We  neglect  to  notice  the 
anoia  that  the  patient  now  exhibits,  an  anoia  that  may 
be  but  mild,  and  that  is  of  course  transitory,  and  we 
neglect  to  notice  it  because  our  attention  is  fixed  upon 
the  patient's  improvement.  We  are  so  intent  upon 
noticing  the  absence  of  the  symptoms  that  are  gone 
that  we  neglect  to  notice  those  that  are  present.  Some 
cases  of  acute  insanity  are  so  transient  that  the  stage 
of  dementia,  if  it  exists,  lasts  a  few  hours  only  and 
escapes  notice  on  that  account.  In  other  cases  the  stage 
is  prolonged,  and  we  may  be  for  some  time  in  doubt 
whether  it  will  clear  up  or  not.  In  many  cases  it  does 
not  clear  up,  and  the  patient  remains  for  the  rest  of  his 
life,  which  may  be  long,  permanently  demented.  When 
the  dementia  thus  follows  an  attack  of  acute  insanity 
of  any  form  it  is  called  terminal  dementia. 

But  dementia  does  not  always  follow  or  begin  in  an 
attack  of  acute  insanity.  It  sometimes  comes  on  gradu- 
ally, and  is  then  known  as  primary  dementia.  I  am 
not  sure  that  it  is  much  more  justifiable  to  take  as  a 
basis  of  classification  the  way  a  disease  begins  than  to 
take  the  way  it  ends.  The  former  has  this  advantage 
over  the  latter,  however,  that  we  usually  know,  or  can 
find  out,  how  the  disease  has  begun,  but  we  can  never 
be  sure  during  its  progress  how  it  is  going  to  end.  If, 
therefore,  we  adopt  the  termination  as  our  basis  of 
classification,  we  cannot  be  quite  sure  that  we  have 
diagnosed  the  disease  correctly,  or  given  it  its  proper 
title  of  dementia  prsecox,  or  what  not,  until  the  patient 
appears  on  the  post-mortem  table.  This  is  inconvenient 
clinically,  and  I  am  not  sure  that  the  advantage  gained 
by  the  use  of  a  comparatively  new  title,  un(^uestionably 


294  A  TEXT-BOOK  OF  INSANITY 

fashionable  as  it  is,  compensates  altogether  for  the 
clinical  inconvenience.  For  my  part,  when  I  am  asked 
by  the  friends  of  my  patients  the  familiar  question, 
*'  What  do  you  call  it,  doctor  ? "  I  feel  reluctant  to 
say,  "Wait  until  he  is  dead;  I  cannot  tell  you  until 
then." 

Primary  dementia  may  come  on  at  any  time  of  life. 
It  is  frequent  in  the  young,  rare  in  middle  life,  and  not 
very  infrequent  in  old  age.  It  is  called  primary,  or  it 
may  be  so  called — the  name  is  become  unfashionable — 
because  it  begins  as  anoia,  continues  as  anoia,  and  ends 
as  anoia ;  that  is  to  say,  the  enfeeblement  and  degra- 
dation of  conduct  and  mind  predominate  over  more 
active  and  positive  symptoms,  though  more  positive 
symptoms  are  seldom  absent.  Since  primary  dementia 
does  not  begin  in  an  attack  of  acute  insanity,  it  comes 
on  gradually ;  and  as  it  comes  on,  so  it  proceeds.  In 
other  words,  it  is  a  progressive  disease,  and  in  this 
respect  it  differs  from  terminal  dementia.  Dementia 
that  is  consequent  on  an  attack  of  acute  insanity  may 
fluctuate  and  alter  for  some  months,  but  after  some 
months  the  patient  settles  down  into  a  permanent  con- 
dition in  which  he  remains  with  little  change  for  the 
rest  of  his  life.  Primary  dementia  on  the  contrary  is  a 
progressive  disease.  It  is  not  regularly  progressive ;  it 
need  not  be  rapidly  progressive ;  for  intervals  it  is 
apparently  stationary  ;  but  on  the  whole,  its  course  is 
not  a  level  course,  but  tends  downwards,  at  first  more 
rapidly,  afterwards  more  slow^ly. 

Although,  as  has  been  said,  primary  dementia  exhibits 
few  active  and  positive  symptoms,  and  what  active  or 
positive  symptoms  there  are  are  subordinate  features 
in  the  case,  and  are  but  unimportant  incidents  in  the 
clinical  picture,  yet  often,  it  may  be  said  usually,  the 


MIND  IN  DEMENTIA  295 

anoia  is  not  quite  simple,  but  is  complicated  by  over- 
action  on  some  lower  level.  In  the  faculty  of  Desire, 
the  sexual  desire  is  often  unduly  and  disagreeably 
prominent.  In  young  dements,  at  any  rate  in  young 
male  dements,  masturbation  is  a  constant  feature.  This 
does  not  necessarily  mean  that  desire  is  augmented ;  it 
means  that  self-control  is  diminished.  Desire  on  the 
lower  middle  level  is  often  disordered.  The  patient  is 
not  determinedly  suicidal,  but  he  is  apt  to  do  impulsively 
acts  of  a  suicidal  character — to  throw  himself  out  of 
window,  for  instance.  On  the  upper  middle  level  he  is 
altogether  deficient,  the  desire  as  well  as  the  ability  to 
earn  his  living  and  administer  his  means  being  absent ; 
and  of  course  the  social  desires  are  the  first  to  go. 

Will  is  often  disordered  in  the  direction  of  impulsive- 
ness ;  sometimes  in  the  direction  of  increased  hesitation, 
sometimes  in  the  direction  of  facility. 

Self- estimation  is  usually  exaggerated,  especially  in 
the  early  stage  and  in  young  people.  This  is  the  exag- 
geration of  a  normal  phase  that  most  young  people  pass 
through.  When  they  first  begin  to  feel  their  feet  and 
realise  that  they  have  powers  of  their  own,  they  over- 
estimate their  own  importance  and  their  own  abilities  ; 
and  in  the  primary  dementia  of  young  people  this  over- 
estimate is  often  still  more  exaggerated.  The  opposite 
condition  of  self-depreciation  is  not  infrequent,  however, 
and  when  it  exists  is  accompanied  by  dysphoria. 

In  the  faculty  of  objective  thought,  delusion  is  not 
very  unusual,  and  the  delusion  is  often  that  of  suspicion 
and  persecution  which  so  often  goes  with  exaggerated 
self-importance.  The  highest  level  of  thought  is  of 
course  abolished,  and  on  the  lowest  level  hallucinations 
testify  to  the  great  depth  that  the  destructive  process 
has  attained. 


296  A  TEXT-BOOK  OF  INSANITY 

Feeling,  both  subjective  and  objective,  shares  in  the 
general  deterioration.  Early  in  the  case  there  may  be 
euphoria  or  dysphoria,  but  at  a  later  stage  these  are 
replaced  by  apathy  and  indifference.  Emotion  may  at 
first  be  excessive  on  slight  provocation,  but  at  length  can 
be  evoked  with  difficulty  or  not  at  all. 

The  primary  dement  sometimes  recovers,  and  but  little 
trace  is  left  of  the  disease,  but  more  often  it  progresses 
to  a  certain  considerable  depth,  at  which  it  remains 
during  the  lifetime  of  the  patient. 


PRIMARY  DEMENTIA  IN  MIDDLE  LIFE 

Primary  dementia  in  the  middle-aged  is  not  a  frequent 
malady,  and  when  cases  do  present  themselves  they  are 
often  very  puzzling.  A  man  in  vigorous  health  and  in 
full  business  employment  finds  his  capacity  failing ;  he 
becomes  stupid ;  he  loses  his  grip  over  his  afiairs ;  he 
forgets  important  appointments  and  other  matters ;  he 
becomes  slovenly  in  dress  and  address ;  his  letters  are 
rambhng,  and  omit  the  subject  they  are  meant  to  refer 
to  ;  but  he  has  no  delusions,  his  conduct  is  not  bizarre 
or  outrageous.  He  is  merely  stupid  and  incompetent. 
This  is  the  way  that  one  form  of  general  paralysis  begins, 
and  such  an  alteration  in  a  man  of  middle  age  raises  a 
suspicion  of  general  paralysis ;  but  no  confirmation  of 
this  suspicion  is  obtained  from  physical  signs,  nor 
from  the  subsequent  progress  of  the  case.  The  man 
becomes  more  stupid.  He  is  obliged  to  retire  from 
business,  and  he  settles  down  at  home,  cared  for  by 
his  women  folk  like  a  child,  prematurely  and  primarily 
demented. 

Primary  dementia  of  middle  life  is  not  the  kind  of 
insanity  characteristic  of  that  time  of  life,  and  therefore 


PRIMARY  DEMENTIA  297 

is  described  here  as  a  type,  modified  by  age.  Senile 
dementia,  however,  is  the  insanity  characteristic  of  that 
time  of  life,  and  is  therefore  described  as  the  insanity 
of  old  age  with  the  other  kinds  of  insanity  characteristic 
of  times  of  life. 


CHAPTER   XII 
IDIOPATHIC  INSANITY  CONTINUED 

INSANITY  FOR  WHICH  THERE  IS  AN  ASSIGNABLE  CAUSAL 

STRESS 

Idiopathic  insanity  for  which  a  cause  can  be  plausibly 
assigned  is  of  three  kinds,  according  to  the  nature  of 
the  stress  that  has  operated  as  a  cause.  For  reasons 
already  stated  I  do  not  include  in  this  class  insanity 
that  is  part  of  a  coexisting  bodily  disease.  Such  insanity 
is  symptomatic,  and  has  already  been  described.  In 
the  present  class  I  include  those  cases  only  with  which 
no  existing  bodily  disease  is  correlated.  The  insanity 
may,  however,  have  originated  in  a  bodily  disease  that 
is  past  and  gone,  and  is  then  analogous  to  the  valvular 
disease  of  the  heart  that  is  left  as  a  substantive  disease 
after  the  rheumatism  that  produced  it  is  past  and  gone. 
Or  it  may  be  that  the  insanity  is  like  the  adherent 
pericardium  that  is  due  to  a  pericarditis  that  is  past  and 
gone.  At  no  time  during  the  existence  of  the  pericarditis 
was  the  pericardium  adherent ;  the  adherent  pericardium 
is  a  sequel  to  the  previous  disease.  And  similarly,  it 
may  be  that  at  no  time  in  the  course  of  influenza  was 
the  patient  insane,  but  yet  the  influenza  may  leave  the 
insanity  behind  as  a  sequel. 

Insanity  due  to  such  direct  stresses  as  the  poison  of 
influenza  constitutes  the  jirst  sub-class  of  those  with 

298 


ALCOHOLIC  INSANITY  299 

which  this  chapter  is  concerned.  The  second  sub-class 
consists  of  those  in  which  the  causal  stress  that  we 
assign  is  incidental  to  the  time  of  life  to  which  the 
patient  has  attained,  and  in  the  third  sub-class  the 
stress  is  that  incidental  to  the  production  of  offspring, 
and  is  confined  to  the  female  sex. 


IDIOPATHIC   INSANITY   DUE   TO   DIRECT   STRESS 

The  chief  of  these  stresses  is  the  long-continued  use 
of  alcohol.  The  poison  of  alcohol  produces  by  its  direct 
action  acute  insanity,  as  has  already  been  described. 
The  long-continued  use  of  alcohol  so  damages,  or  may 
damage,  the  structure  of  the  brain  as  to  produce  chronic 
insanity,  which  remains  even  though  the  use  of  alcohol 
is  discontinued.  It  may  be,  of  course,  that  a  person 
who  is  accustomed  to  exceed  in  alcohol  may  present  a 
combination  of  both  types,  part  of  his  insanity  being 
due  to  the  alcohol  now  circulating  in  his  brain,  and  part 
to  the  permanent  damage  done  by  previous  doses.  In 
such  a  case,  if  the  alcohol  is  discontinued,  the  insanity 
is  always  mitigated  by  the  disappearance  of  that  part 
which  is  due  to  the  actual  presence  of  alcohol  in  the 
brain,  and  what  insanity  is  left  is  that  which  is  due  to 
permanent  damage.  Of  this  permanent  insanity  there 
are  two  kinds. 

In  the  first  kind  there  is  a  general  degradation  of 
most  or  all  of  the  faculties  of  mind,  but  especially  a 
moral  degradation.  The  habitual  drunkard  almost 
inevitably  sinks  in  the  social  scale.  His  habits  at  table 
become  disgusting.  His  conduct  generally  deteriorates 
until  his  family  become  ashamed  of  him  and  shrink 
from  allowing  him  to  associate  with  their  friends.  He 
geeks  companions  fa?  belpw  him  in  social  position.    He 


300  A  TEXT-BOOK  OF  INSANITY 

becomes  a  liar  and  a  sponge,  indifferent  to  the  means  by 
which  he  gets  his  drink,  so  that  he  gets  it.  A  man  or 
woman  of  good  birth  and  social  position  frequents  low 
pot-houses  and  boozes  with  low  companions.  He 
becomes  a  byword  and  a  reproach.  With  this  degrada- 
tion of  conduct  and  mind — he  does  not  recognise  hia 
own  degradation,  and  is  therefore  insane — go  usually 
certain  physical  symptoms.  On  first  rising  in  the 
morning  he  retches  violently ;  his  eyes  become  watery, 
his  hands  tremulous,  and  sometimes,  but  not  often,  he 
resembles  Bardolph  in  his  bottle  nose. 

The  second  kind  of  chronic  alcoholic  insanity  exhibits 
some  of  the  moral  degradation  of  the  first,  but  these 
symptoms  are  swamped  and  overcome  by  others — by 
suspicion,  delusion,  a  peculiar  disorder  of  memory, 
hallucinations,  and  various  sensory  disturbances  and 
motor  defects. 

Suspicion  is  usually  a  prominent  feature  in  alcoholic 
insanity.  The  patient  believes  that  his  food  is  poisoned, 
that  his  wife  is  unfaithful,  that  his  children  are  con- 
spiring against  him,  that  he  is  to  be  tortured  and 
destroyed  ;  and,  combined  as  this  attitude  of  mind  is 
with  hallucination,  it  is  apt  to  be  confused  with  paranoia, 
which  it  often  closely  resembles.  It  is  important  to  dis- 
criminate between  the  two,  for  the  insanity  of  alcohol 
is  far  more  improvable  than  paranoia,  and  the  prognosis 
therefore  much  better,  and  the  treatment  is  different. 
The  diagnosis  is  not  usually  difficult,  the  defect  of 
memory  and  the  motor  disturbance  of  alcoholic  insanity 
being  sufficient,  apart  from  the  history,  to  establish  the 
difference. 

The  delusions  are  often  those  of  pure  suspicion  and 
persecution,  such  as  have  been  instanced  ;  but  there  is 
often  a  strain  of  vainglory  and  boastfulness  running 


ALCOHOLIC  INSANITY  301 

through  them  in  addition.  The  patient  believes  him- 
self to  be  rich,  to  be  a  great  personage,  but  at  the  same 
time  people  are  conspiring  to  rob  him  of  his  money  or 
his  rank.  He  has  not  the  confident  security  of  the 
ordinary  megalomaniac,  the  general  paralytic,  or  the 
man  with  fixed  delusion. 

The  disorder  of  memory  is  usually  a  prominent  feature 
in  alcoholic  insanity.  There  is  usually  marked  defect, 
and  the  defect  is  the  same  in  character  as  the  defect  in 
old  age — that  is  to  say,  the  memory  of  long-past  events 
is  tenacious  and  faithful,  but  the  current  events  of  daily 
life  are  swept  out  of  the  memory  as  soon  as  they  have 
happened.  The  patient  receives  a  visit  from  his  wife, 
who  spends  an  hour  with  him,  and  ten  minutes  after 
she  has  gone  he  has  forgotten  all  about  the  visit,  and 
vows  that  she  has  not  been  near  him.  He  worries 
because  he  has  not  written  a  letter,  which  he  has  written 
and  delivered  to  be  posted  a  dozen  times  or  more.  He 
has  very  little  notion  of  the  lapse  of  time,  and  if  he  does 
remember  a  recent  event,  he  cannot  tell  whether  it 
occurred  to-day  or  yesterday,  or  a  week  or  a  month  ago. 
Together  with  this  defect,  there  is  a  peculiar  delusion 
of  memory  which  is  not  so  pronounced  or  so  frequent 
in  any  other  variety  of  insanity.  The  patient  remembers 
vividly  and  in  detail  events  which  have  never  occurred 
at  all.  He  will  describe  visits  that  he  thinks  he  has 
paid,  will  repeat  conversations  that  he  believes  he  has 
taken  part  in,  scenes  that  he  thinks  that  he  has  witnessed, 
none  of  which  have  ever  taken  place  at  all.  It  some- 
times happens  that  the  imaginary  events  which  he 
describes,  and  fully  believes  that  he  has  witnessed,  are 
assaults  upon  himself  or  others,  and  he  then  becomes  a 
dangerous  person. 

Hallucinations  occur  more  constantly  in  alcoholic 


302  A  TEXT-BOOK  OF  INSANITY 

insanity  than  in  any  other  variety  of  insanity  except 
paranoia.  They  are  usually  aural,  sometimes  visual, 
and  not  infrequently  affect  the  sense  of  smell  or  taste. 
They  are  always  unpleasant  and  disconcerting,  and 
usually  work  in  with  and  corroborate  the  delusions  of 
suspicion.  The  evil  taste  or  smell  that  he  experiences 
confirms  his  opinion  of  poison  in  his  food.  The  voices 
that  he  hears,  the  texts  that  he  sees  written  upon  the 
walls,  corroborate  the  suspicion  of  persecution  to  which 
he  is  subject. 

Of  the  motor  disturbances,  which  are  rarely  absent 
in  alcoholic  insanity,  the  chief  is  tremor,  which  is 
usually  pronounced.  It  occurs  first  and  most  in  the 
hands,  but  it  subsequently  afiects  the  lips  and  articula- 
tory  organs  generally.  It  is  present  both  in  rest  and 
during  voluntary  movement,  but  is  more  pronounced 
in  the  latter.  Following  on  tremor  of  the  hands  comes 
a  peculiar  gait,  which  is  neither  a  reel  nor  ataxy,  but 
a  kind  of  stringhalt ;  and  the  patient  wavers  in  hia 
walk  so  that  his  course  is  not  a  straight  line  but  an 
irregular  zig-zag.  Cramp  in  the  calf  of  the  leg  is  often 
frequent  and  severe  in  alcoholic  insanity,  and  occasion- 
ally convulsions  occur  in  its  course.  Shght  irregularity 
of  the  pupils  is  not  uncommon  in  alcoholic  insanity,  as 
in  many  other  morbid  states,  and  the  reactions  are  apt 
to  be  sluggish,  but  they  are  never  absent. 

Alcoholic  insanity  often  simulates  paranoia,  from 
which  it  may  be  distinguished  as  already  described. 
Its  symptoms  are  often  closely  similar  to  those  of 
general  paralysis,  and  there  are  cases  in  which  the 
diagnosis  cannot  be  made,  and  we  have  to  wait  for  the 
course  of  the  case  to  clear  up  the  difficulty.  The  history 
is  not  to  be  depended  upon,  for  drunkards  very  often 
deny  their  habit,  and  general  paralytics  have  often  been 


ALCOHOLIC  INSANITY  303 

intemperate.  The  tremor  is  closely  alike  in  the  two 
cases.  In  the  early  stage  of  general  paralysis  it  is  never 
so  marked  as  it  sometimes  is  in  the  early  stage  of  alco- 
holic insanity ;  but  sometimes  in  the  latter  there  is 
little  or  no  tremor.  If  the  peculiar  mnemonic  delusions 
of  alcoholism  are  present,  their  presence  is  almost 
decisive,  but  the  delusions  of  general  paralysis  often 
approach  them  in  character.  The  chief  reliance  must 
be  placed  upon  the  pupillary  reactions.  It  has  been 
said  that  these  reactions  are  sometimes  lost  in  alcoholic 
insanity,  but  this  is  not  my  experience.  If  either  the 
reaction  to  light  or  that  to  accommodation  is  lost,  or  is 
seriously  defective,  then  I  believe  that  general  paralysis 
may  be  diagnosed  without  hesitation.  The  difficulty  is 
that  in  the  early  stage  of  general  paralysis  there  is  some- 
times no  such  sufficient  defect  in  these  reactions  as  to 
enable  us  to  make  a  diagnosis,  which  must  then  remain 
in  doubt.  The  importance  of  clearing  up  the  matter  as 
soon  as  possible  is  very  great,  for  general  paralysis  is 
almost  certainly  fatal,  while  alcoholic  insanity  is  very 
improvable,  and  is  compatible  with  considerable  dura- 
tion of  life. 

Since  the  various  reactions  characteristic  of  syphiHs 
have  been  discovered,  it  has  been  usual  to  accept  a 
positive  reaction  as  conclusive  evidence  of  general 
paralysis  in  a  doubtful  case.  This  practice  is  fallacious. 
Drunkards  are  not  immune  from  syphilis,  and  it  may 
well  be  that  a  person  who  is  both  syphilitic  and  a 
drunkard  may  suffer  from  alcoholic  insanity  but  not 
from  general  paralysis.  Every  syphilitic  does  not  be- 
come a  general  paralytic^  and  this  is  true  whether  he  is 
a  drunkard  or  not. 

In  the  treatment  of  alcoholic  insanity,  the  first  thing 
to  be  done  is  to  deprive  the  patient  of  his  alcohol,  and 


304  A  TEXT-BOOK  OF  INSANITY 

this  can  only  be  done  by  sending  him  to  an  institution. 
It  is  quite  futile  to  attempt  to  treat  such  cases  in  their 
own  homes,  for  there  they  will  always  find  means  to 
obtain  their  poison.  It  does  not  matter  what  vigilance 
is  exercised,  they  will  endeavour  to  corrupt  their  nurses 
or  servants,  and  they  will  succeed  at  last.  They  are 
sure  to  have  a  secret  store  bestowed  somewhere  about 
the  house  to  which  they  will  get  access  at  times.  The 
only  possible  chance  of  completely  depriving  them  is 
to  place  them  in  a  lunatic  asylum.  The  Jfirst  week 
of  their  deprivation  will  be  a  terrible  time  for  them. 
They  will  suffer  agonies  of  depression  and  misery,  will 
become  perhaps  riotously  maniacal,  and  will  give 
endless  trouble  by  their  false  accusations  and  general 
perversity.  The  alcohol  need  not  be  absolutely  with- 
held, and  by  withdrawing  it  suddenly  we  may  produce 
an  attack  of  delirium  tremens.  Sleep  is  often  better 
obtained  if  a  dose  of  whiskey  in  hot  milk  is  given 
at  night ;  and  when  the  misery  becomes  very  great, 
the  same  remedy  will  give  relief.  So  long  as  the 
patient  is  in  the  institution,  we  have  him  under 
absolute  control,  and  we  need  not  fear  the  result  of  an 
occasional  dose  of  stimulant.  He  probably  suffers  from 
gastritis,  more  or  less,  and  this  must  be  treated,  espe- 
cially as  it  is  important  in  this,  as  in  acute  insanity,  to 
feed  copiously.  Iron  and  bitter  tonics  will  be  found 
useful,  but  the  chief  reliance  is  to  be  placed  upon 
deprivation  of  alcohol,  copious  feeding,  regular  hours, 
and  fresh  air.  In  these  circumstances  the  improvement 
that  takes  place  is  often  surprising.  The  patient  in 
a  few  months  becomes  so  well  that  it  is  very  dijB&cult 
to  detain  him  in  an  institution  ;  and  yet,  if  he  is  dis- 
charged, he  will  certainly  return  to  his  drinking  habits 
and  relapse. 


SEQUELAE  INSANITY  305 

SEQUELAE  INSANITY 

The  second  direct  stress  that  leaves  insanity  behind 
it  as  a  sequel  is  the  poison  of  specific  fever.  We  have 
already  seen  that  this  is  probably  an  efiect  in  some 
cases  of  acute  specific  fevers  occurring  in  childhood. 
They  appear  to  arrest  the  development  of  the  brain, 
and  the  child  does  not  advance,  or  does  not  much 
advance,  in  mental  capacity  after  the  attack.  In  adults 
an  attack  of  specific  fever  may  be  followed  by  insanity, 
and  though  such  an  event  is  rare,  it  does  sometimes 
happen  after  smallpox,  typhoid  fever,  and  perhaps  other 
acute  specific  diseases.  The  fever  which  leaves  this 
result  behind  it  with  the  greatest  frequency  is  influenza, 
perhaps  because  the  occurring  cases  of  influenza  are  far 
more  numerous  than  those  of  any  other  specific  fever. 
Post-influenzal  insanity  has  no  constant  form  or  type. 
It  is  sometimes  acute,  sometimes  chronic.  In  the 
acute  type  it  is  usually  melancholic,  in  the  chronic  it  is 
usually  dementia,  but  I  have  seen  a  case  with  delusions 
of  persecution,  indistinguishable  from  paranoia,  follow 
upon  influenza. 

INSANITY   OF  TIMES   OF  LIFE 

The  next  stress  that  may  be  assigned  as  a  cause  of 
insanity  is  that  incident  to  the  time  of  life  at  which  the 
patient  has  arrived.  How  this  may  be  supposed  to  act 
as  a  stress  has  already  been  considered  under  the  causes 
of  insanity.  Certain  it  is  that  insanity  does  occur 
definitely  in  connection  with  the  time  of  life  at  which 
the  patient  is,  and  is  often  of  such  constant  form  and 
type  that  we  must  suppose  that  the  connection  is 
causal. 


306  A  TEXT-BOOK  OF  INSANITY 

INSANITY   OF  CHILDHOOD 

In  the  previous  edition  of  this  book  I  followed  authority 
in  saying  that  insanity,  apart  from  idiocy  and  less 
extreme  forms  of  congenital  weak-mindedness,  is  very 
rare  in  childhood.  Wider  experience  leads  me  to  give 
a  different  opinion.  I  have  now  seen  many  cases  of 
insanity  in  childhood,  cases  in  which  there  was  no  reason 
to  suspect  that  the  insanity  was  congenital.  The  cases 
I  have  seen  have  been  in  two  classes,  in  one  of  which 
the  insanity  comes  on  about  the  age  from  six  to  eight, 
and  in  the  other  about  fifteen. 

Children,  both  boys  and  girls,  well  born  and  well 
brought  up  by  careful  mothers  in  moral  surroundings, 
sometimes  become,  about  the  age  of  six  to  eight,  in- 
corrigible thieves.  They  are  usually  intelligent,  and 
sometimes  precociously  clever.  It  is  not  that  they  do 
not  understand  the  moral  lessons  conveyed  to  them, 
but  that  they  are  unable  to  profit  by  them.  They 
usually  deny  their  thefts,  even  when  the  evidence  against 
them  is  overwhelming ;  and  the  mark  of  this  kind  of 
thief  is  that  punishment  has  no  deterrent  effect  upon 
them  whatever.  "  I  have  beaten  him,"  one  mother  said 
to  me,  "  until  I  am  tired."  They  do  not  usually  take 
much  care  to  escape  detection,  and  they  will  steal  under 
circumstances  in  which  detection  is  certain  and  punish- 
ment speedy.  They  will  steal  even  if  the  cane  is  up- 
lifted over  them,  ready  to  strike  the  moment  they  have 
completed  the  theft.  Such  children  occasionally  grow 
up  into  criminals — stupid,  vindictive  criminals — who  lie 
and  steal,  and  are  guilty  of  impostures  that  do  not 
benefit  them,  of  frauds  that  bear  the  character  of  fraud 
upon  their  face,  criminals  who  will  take  more  trouble 
to  get  a  precarious  and  insufficient  living  by  dishonesty 


ADOLESCENT  INSANITY  307 

than  it  would  cost  them  to  earn  an  honest  living  by  an 
honourable  life.  But  such  cases  are  very  exceptional. 
The  great  majority  of  such  children  grow  out  of  their 
dishonesty  and  develop  into  honest  and  honourable  men 
and  women. 

The  second  class  of  children  become  insane  at  a  later 
age,  usually  at  about  fifteen,  and  in  them  the  insanity 
is  always  in  my  experience  associated  with  excessively 
rapid  growth.  They  shoot  up  in  height  and  they  fill  out 
in  bulk  with  extreme  rapidity,  and  children  who  are 
thus  growing  should  always  be  watched  with  vigilance 
and  their  studies  interrupted  until  they  have  done  grow- 
ing. The  form  that  disorder  of  conduct  takes  in  these 
cases  is  a  peculiar  one.  I  have  not  seen  it  in  girls,  but 
in  boys  it  takes  the  form  of  ordering  from  tradesmen 
goods  that  they  cannot  pay  for  and  have  no  intention 
of  paying  for.  One  will  order  a  motor-car,  another  will 
stay  at  expensive  hotels,  live  on  a  royal  scale,  and  depart 
without  paying  his  bill.  A  third  ordered  a  magnificent 
gold  watch,  and  instructed  the  tradesman  of  whom  he 
purchased  it  to  place  upon  it  a  laudatory  inscription 
stating  that  it  was  presented  to  the  boy  by  his  admiring 
school-fellows.  The  phase  passes  away  in  a  few  months 
when  bodily  growth  comes  to  an  end,  and  the  energy 
drafted  off  for  this  purpose  is  again  at  the  service  of  the 
brain. 

ADOLESCENT  INSANITY 

Adolescence  is,  for  reasons  stated  in  a  previous 
chapter,  a  time  of  life  at  which  insanit)^  is  frequent — 
perhaps  more  frequent  than  at  any  other.  By  adoles- 
cence I  mean  from  about  eighteen  to  about  twenty-five. 
Any  insanity  occurring  at  this  time  of  life  is  coloured  by 
the  mental  peculiarities  that  prevail  at  this  time  of  life, 


308  A  TEXT-BOOK  OF  INSANITY 

but  there  is  no  insanity  that  is  peculiar  to  adolescence. 
The  kinds  of  insanity  most  often  seen  at  this  early  time 
of  life  are  acute  insanity  and  primary  dementia.  The 
stuporose  form  of  acute  insanity  is  rarely  seen  at  any 
other  age. 

CLIMACTERIC  INSANITY 

Not  every  case  of  insanity  that  occurs  at  the  time 
of  the  menopause  is  climacteric  insanity.  Women  at 
the  climacteric  are  not  exempt  from  the  causes  that 
may  produce  insanity  at  other  times  of  life,  except  of 
course  to  those  incident  to  child-bearing ;  and  when 
they  become  insane  from  these  other  causes  their 
insanity  is  not  climacteric  insanity.  True  climacteric 
insanity  has  certain  specific  features  by  which  it  may 
be  recognised.  It  begins  as  an  acute  or  sub-acute 
insanity,  becoming  acute,  of  gradual  onset,  and  always 
of  melancholic  type,  associated  with  suspicion  and 
terror,  and  with  attempts  at  suicide.  The  patient  is 
very  apt  to  have  delusions  of  suspicion,  as  distinguished 
from  delusions  of  persecution.  She  thinks  her  food  is 
poisoned,  that  something  dreadful  is  going  to  happen, 
or  has  happened  ;  that  she  has  lost  all  her  money,  and 
perhaps  been  robbed  of  it.  Sometimes  the  delusions 
have  a  sexual  colouring.  An  old  maid  thinks  she  has 
been  seduced,  she  has  been  unchaste,  she  is  engaged  to 
this  man  or  that,  to  whom  perhaps  she  has  never  spoken. 
There  is  nothing  special  in  the  treatment.  The  prog- 
nosis is  not  unfavourable,  but  the  duration  of  the  disease 
is  likely  to  be  longer  than  in  the  insanities  connected 
with  child-bearing.  In  these  we  expect  recovery  to 
take  place,  if  at  all,  within  a  year,  and  often  within  six 
months.  In  the  insanity  of  the  climacteric  it  is  unwise 
to  expect  recovery  under  eighteen  months  or  two  years. 


SENILE  INSANITY  309 

SENILE  INSANITY 

Dementia  is  one  of  the  terminations  of  life.  In  the 
vast  majority  of  cases  life  is  cut  short  by  accident,  or 
by  the  quasi-accident  of  bodily  disease  ;  but  when  it 
goes  on  until  it  ceases  from  pure  exhaustion  of  the 
quantum  of  energy  that  it  received  at  conception,  it  may 
pass  through  dementia  on  its  way  to  the  end.  Some 
degree  of  dementia,  some  diminution  of  the  vividness 
of  feeling,  of  the  capacity  of  thought,  of  the  range  and 
variety  of  conduct,  is  the  natural  and  inevitable  accom- 
paniment of  the  decay  of  the  bodily  power  in  old  age  ; 
and  it  often  happens  that  the  decay  of  the  highest 
regions  of  the  brain  outstrips  that  of  the  body,  so  that 
the  dementia  sets  in  earlier,  is  more  pronounced  in 
degree,  and  is  more  irregular  in  its  manifestations  than 
is  usual  and  normal  in  old  age,  and  is  out  of  proportion 
to  the  decay  of  the  bodily  capacity.  The  condition 
then  presented  is  the  clinical  condition  of  senile  dementia. 

In  senile  dementia  the  most  conspicuous  feature  is 
defect  of  memory ;  the  most  conspicuous  fault  is  the 
outbreak  of  ill-temper.  The  defect  of  memory  is  peculiar, 
and  is  characterised  by  the  evanescence  of  the  memory 
of  passing  experiences  while  the  memories  of  long-past 
experiences  are  not  only  retained,  but  are  increased  in 
their  prominence,  in  their  intensity,  and  in  the  frequence 
with  which  they  are  present  in  consciousness.  The  first 
approaches  of  senility,  which  are  perceptible  between 
forty  and  fifty,  are  marked,  as  has  been  said,  by  an 
inability  to  recall  newly  acquired  names,  whether  of 
persons  or  of  things,  and  generally  by  a  want  of  nimble- 
ness  in  the  use  of  substantives.  As  age  advances, 
experiences  produce  impressions  that  are  less  and  less 
enduring,  and,  in  the  dementia  of  old  age,  become  so 


310  A  TEXT-BOOK  OF  INSANITY 

transient  that  events  are  not  remembered  from  hour  to 
hour,  and  often  not  from  minute  to  minute.  A  senile 
dement  will  declare  that  he  has  not  seen  for  months  a 
person  who  spoke  to  him,  and  whom  he  recognised  and 
answered,  five  minutes  before  he  makes  the  declaration  ; 
and  no  matter  how  important  or  impressive  the  event, 
its  memory  is  equally  evanescent.  While  he  thus  forgets 
with  abnormal  celerity  and  completeness  current  events, 
he  retains  with  punctual  fidelity  the  memories  of 
experiences  that  he  underwent  in  youth,  and  is  able 
to  give  accurate  descriptions  of  events  that  happened 
fifty  or  sixty  or  more  years  ago.  Nor  is  this  all ;  the 
memories  of  long-past  experiences  are  not  only  faithful, 
often  surprisingly  and  unusually  faithful  and  detailed, 
but  they  thrust  themselves  forward  and  occupy  a  much 
larger  share  of  consciousness  than  is  usual.  People  in 
Doiddle  life,  and  normal  people  in  old  age,  are  occupied 
mainly  with  the  current  experiences  of  their  daily  life  ; 
and  the  reminiscences  of  childhood  are  before  the  mind 
but  seldom,  and  for  short  periods.  But  in  many  cases 
the  senile  dement  lives  his  childhood  over  again.  He 
is  perpetually  maundering  about  things  that  happened 
before  his  hearers  were  born,  about  the  events  of  his 
school  life  and  his  early  love  affairs,  and  not  very 
infrequently  these  memories  of  bygone  experiences 
take  such  hold  upon  him  that  he  actually  mistakes 
the  people  about  him  for  the  companions  of  his  early 
life.  He  addresses  his  grandchildren  by  the  names  of 
his  schoolfellows,  and  takes  his  daughter  for  his  first 
sweetheart. 

Together  with  this  peculiar  defect  of  memory  there 
is  usually  in  senile  dementia  an  irritabihty  of  temper, 
a  petulance  and  impatience,  which  reproduce  the 
peculiarities  of  a  spoilt  child.     If  they  want  a  thing, 


INSANITY  OF  PREGNANCY  311 

they  must  have  it  on  the  instant ;  they  cannot  wait 
until  it  is  prepared  or  until  it  is  fetched ;  they  must 
have  it  now,  this  moment ;  and  if  it  is  not  forthcoming 
they  fly  into  a  rage,  they  stamp,  they  shout,  they 
swear,  and  they  often  offer  such  feeble  violence  as 
they  are  capable  of.  Like  the  child,  too,  they  are 
easily  coaxed  into  a  good  humour  again  ;  their  ill- 
temper  is  transient,  and  its  occasion  soon  forgotten. 
Another  characteristic  is  the  wearisome  iteration  with 
which  they  will  repeat  the  same  thing,  their  defect 
of  memory  rendering  them  oblivious  to  the  frequency 
of  the  repetition.  Indeed,  the  repetition  of  the  same 
story  at  short  intervals  to  the  same  person  is  as  common 
an  indication  of  the  advent  of  senility  as  is  the  difficulty 
of  dealing  with  substantives  that  has  already  been 
mentioned. 

INSANITIES   OF  REPKODUCTION 

Insanity  of  Pregnancy 

It  is  remarkable  that  although  all  women  are  so 
liable  during  pregnancy  to  emotional  disturbances,  un- 
provoked "  hysterical  "  laughing  and  weeping,  "  long- 
ings," caprices  of  all  kinds,  and  other  mental  disturbance, 
yet  disturbance  to  the  point  of  actual  insanity  is  rare  in 
pregnancy.  When  it  does  occur,  it  occurs  either  about 
the  third  month,  as  an  exaggeration  of  the  longings  and 
caprices  that  normally  appear  then,  or  about  the  sixth 
month,  or  later,  it  comes  on  gradually  as  the  foetus 
grows.  The  latter  variety  is  the  more  frequent  and  the 
more  severe,  the  first  variety  sometimes  recovering  in 
the  later  months  of  pregnancy,  while  the  latter  never 
recovers  until  after  delivery. 

The  form  of  the  insanity  of  pregnancy  is  an  acute 


312  A  TEXT-BOOK  OF  INSANITY 

or  sub-acute  insanity  of  melancholic  type,  with  suicidal 
inclination.  The  delusions  are  often  coloured  by  the 
condition  of  the  patient,  who  imagines  that  she  herself 
or  her  husband  has  been  unfaithful,  or  has  other  de- 
lusions in  which  the  husband  is  concerned,  as  that  she 
has  ruined  him. 

As  already  said,  when  the  insanity  comes  on  about 
the  third  month  after  the  pregnancy,  it  may  recover 
before  delivery ;  but  when  it  comes  on  in  the  later 
stages,  it  never  recovers  till  the  child  is  born.  In  a 
minority  of  cases  the  birth  of  the  child,  whether  pre- 
maturely or  at  term,  is  followed  by  rapid  recovery ; 
in  other  cases  the  insanity  continues  without  change ; 
and  in  yet  a  third  class  it  undergoes  an  exacerbation 
a  few  days  after  labour,  as  if  puerperal  insanity  were 
added  to  that  of  pregnancy.  Hence  the  rule  is  not  to 
bring  on  premature  labour  in  the  hope  of  terminating 
the  insanity  by  that  means,  but  the  rule  ought  by  no 
means  to  be  slavishly  adhered  to  in  all  cases.  In  some 
cases,  and  especially  when  the  insanity  is  very  acute 
and  severe,  it  is  justifiable,  and  is  followed  by  speedy 
recovery. 

The  treatment  of  the  insanity  of  pregnancy  is  that 
of  acute  insanity  of  melancholic  type,  but  with  this 
difference — that  since  whatever  drugs  are  given  to  the 
woman  are  given  to  the  child  in  her  womb  also,  the 
administration  of  drugs  is  to  be  cautious,  and  is  to  be 
minimised.  As  in  other  varieties  of  insanity  connected 
with  reproduction,  the  prognosis  is  not  unfavourable. 
About  three-fourths  of  the  cases  recover. 

PUERPERAL  INSANITY 

The  puerperium  is  a  common  occasion  of  insanity 
in  women,  insanity  occurring  in  about  a  quarter  per 


PUERPERAL  INSANITY  313 

cent,  of  all  confinements,  and  being  responsible  for 
about  seven  per  cent,  of  all  cases  of  insanity  in  women. 
It  is  most  common  in  primiparae  and  within  the  first 
week  after  labour,  it  is  less  common  in  the  second  week, 
and  after  that  time  it  is  rare  ;  but  insanity  occurring 
within  six  weeks  of  labour  is  called  still  puerperal,  and 
partakes  of  the  character  of  puerperal  insanity.  Should 
insanity  occur  after  this  period,  it  is  the  insanity  of 
lactation. 

Puerperal  insanity  is  always  an  acute  insanity,  and 
may  be  of  any  of  the  types  of  that  malady  that  have 
been  described,  or  of  some  intermediate  grade  between 
two  or  more  of  them,  but  usually  it  is  maniacal-melan- 
cholic in  character.  In  addition  to  the  description  that 
has  already  been  given  of  acute  insanity,  there  are 
certain  characters  special  to  the  puerperal  variety.  The 
impulsive  violence  so  often  seen  in  acute  insanity  is, 
in  puerperal  insanity,  usually  directed  against  the 
infant,  which  should  be  immediately  removed  to  a  place 
of  safety.  Often,  but  by  no  means  always,  there  is  a 
septic  element  in  the  disease.  The  lochia  become  ofien- 
sive,  the  uterus  is  tender,  the  temperature  is  raised,  the 
pulse  rapid  and  weak,  the  lips  are  dry  and  the  tongue 
foul.  In  such  cases  the  uterus  must  be  examined, 
and,  if  necessary,  cleaned  out,  and  the  usual  sanitary 
precautions  taken.  In  other  respects  the  treatment  is 
that  already  prescribed  for  acute  insanity. 

The  treatment  is  usually  successful,  perhaps  because 
the  patients  are  always  got  under  treatment  early.  It 
is  usually  necessary  to  remove  the  patient  to  an  institu- 
tion, and  here  she  commonly  recovers.  The  recovery  is 
often  interrupted  by  relapses,  sometimes  serious,  though 
usually  slight,  and  for  this  reason,  and  because  the 
relapse  is  likely  to  be  much  more  serious  at  home 


314  A  TEXT-BOOK  OF  INSANITY 

than  in  an  institution,  and  especially  because,  even 
wlien  recovered,  the  patient  ought  not  for  several 
months  to  resume  marital  relations,  the  stay  at  the 
institution  ought  to  be  prolonged.  The  subjects  of  puer- 
peral insanity  often  recover  with  apparent  completeness 
in  three  months  ;  but  they  should  rarely  be  allowed 
to  go  home  before  the  child  is  six  months  old.  A  rough 
practical  rule  is  not  to  discharge  the  patient  until  men- 
struation is  re-established ;  but  this  will  not  always  work, 
although  the  re-establishment  of  menstruation  is  often 
the  sign  of  complete  recovery,  and  a  considerable  mental 
improvement  occurring  at  the  same  time  is  of  excellent 
augury.  But  when  no  improvement  accompanies  the 
occurrence  of  a  menstrual  period,  the  prognosis  is  bad. 

Puerperal  insanity  is  remarkable  as  being  the  only 
form  of  insanity,  except  acute  dehrious  mania,  in  which 
the  temperature  is  raised  except  from  accidental  causes. 

INSANITY   OP  LACTATION 

This  is  an  insanity  of  starvation,  of  exhaustion.  It 
occurs  mainly  in  the  later  months  of  suckling,  and 
among  women  who  suckle  their  babies  freely  and  long, 
work  hard,  and  are  perhaps,  in  addition,  insufficiently 
fed  ;  and  is  rare  among  the  well-to-do.  Agreeably  to 
its  causation,  it  is  an  acute  insanity  of  melancholic 
type  (which  see),  and  is  very  amenable  to  treatment. 
Fully  three-fourths  of  the  cases  recover. 


PAET  III 
THE  LEGAL  EELATIONS  OF  INSANITY 


CHAPTER   XIII 

THE   LEGAL  RELATIONS   OF  INSANITY 

Insanity  differs  from  all  other  diseases  in  this  respect, 
that  the  patient  may  retain  all  his  physical  ability,  but 
yet  is  incapacitated  by  his  disease  from  being  a  normal 
constituent  of  a  social  body.  The  disease  always  affects 
his  social  relations,  and  diminishes  his  usefulness  as  a 
social  unit,  and  it  may  make  him  noxious  to  the  social 
body  to  which  he  belongs — noxious  either  passively  by 
rendering  him  a  burden  on  it  for  his  support,  or  actively 
by  reason  that  the  disorder  of  his  conduct  is  dangerous 
to  the  lives,  or  harmful  to  the  property,  or  outrageous 
to  the  feelings  of  his  fellows.  In  addition  to  this  in- 
capacity to  take  his  place  as  a  normal  and  useful  social 
unit,  he  usually  presents  also  an  incapacity  to  manage 
his  own  life  profitably.  The  disorder  of  his  conduct  is 
of  such  a  nature  that  it  menaces  not  only  the  lives,  well- 
being,  or  comfort  of  others,  but  also  menaces  his  own 
life,  either  directly,  or  through  the  loss  or  perversion 
of  his  means  of  livelihood.  For  these  reasons,  firstly 
for  its  own  welfare,  and  secondly  for  the  welfare  of  the 
lunatic  himself,  society  has  always,  and  rightly,  con- 
cerned itself  about  the  treatment  of  the  lunatic  in  a 
way  that  it  has  never,  until  very  lately,  concerned  itself 
about  the  treatment  of  those  whose  illness  does  not 
directly  affect  their  conduct. 

The  first  duty  and  the  first  necessity  of  society  is  to 

317 


318  A  TEXT-BOOK  OF  INSANITY 

protect  itself ;  and  the  element  in  insanity  that  first 
attracted  the  notice  of  society  was  the  noxiousness  of 
the  lunatic  to  itself.  Early  legislation  for  lunatics  was 
therefore  directed  exclusively  to  safeguarding  society 
by  locking  them  up.  If  the  lunatic  was  not  noxious 
to  society  he  was  left  alone,  and  there  was  scarcely  a 
village  in  this  kingdom  that  had  not  its  harmless  idiot, 
who  was  the  butt  of  the  children  and  the  recipient  of 
charity  from  their  elders.  With  the  immense  develop- 
ment of  sympathy  and  charity  that  has  distinguished 
the  last  hundred  years  above  any  other  period  in  the 
history  of  the  human  race,  a  new  view  is  taken  of  the 
duty  of  society  to  the  lunatic,  and  he  is  now  taken  out 
of  the  body  of  society  and  locked  up  in  an  asylum  not 
only  when  he  is  noxious  to  society,  but  when,  and 
because,  he  cannot  sufficiently  safeguard  himself  from 
the  common  ills  of  life. 

Whether  to  safeguard  itself,  or  whether  to  safeguard 
the  lunatic,  society,  through  the  medium  of  the  law, 
has  provided  that  he  shall  be  placed  and  kept  under 
control,  and  in  order  that  this  placing  and  keeping 
under  control  shall  be  restricted  to  lunatics  and  not  be 
improperly  applied  to  sane  persons,  the  law  requires 
certain  formalities,  which  will  presently  be  explained, 
to  be  observed.  Statute  law,  however,  is  necessarily 
too  rigid  to  adapt  itself  perfectly  to  the  infinite  varia- 
bility of  human  affairs,  and  there  are  on  the  one  hand 
certain  cases  for  which  it  does  not  provide,  and  on  the 
other  certain  cases  for  which  it  provides  needlessly. 

The  formalities  required  for  placing  a  lunatic  legally 
under  control  necessarily  take  time ;  and  there  are 
cases  in  which  time  cannot  be  afiorded.  If  a  lunatic  is 
at  large  with  arms  in  his  hands  and  threatening  or 
actually  taking  the  lives  of  his  fellow-citizens,  urgent 


CERTIFIABILITY  319 

necessity  supersedes  the  statute  law,  and  the  common 
law,  the  organised  common  sense  of  many  generations, 
authorises  us  to  deal  with  him  in  the  best  way  we  can, 
even  if  we  have  to  shoot  him  to  stop  his  depredations. 
Short  of  shooting  him,  we  may  maim  him  or  tie  him 
down,  or  do  anything  that  seems  on  the  spur  of  the 
moment  the  most  effectual  and  judicious  thing  to  do. 

On  the  other  hand,  there  are  many  cases  for  which  the 
law  provides  needlessly.  In  strict  law  it  would  be 
necessary  for  every  patient  in  a  nursing  home  who  is 
dehrious  from  fever,  or  from  the  effect  of  an  anaesthetic,  to 
be  promptly  certified  as  insane,  which  he  is  ;  but  this 
is  never  done  unless  the  delirium  is  very  prolonged  and 
becomes  the  dominant  feature  in  the  case.  Similarly, 
there  are  many  general  paralytics  in  whom,  towards  the 
end  of  their  malady,  the  bodily  incapacity  is  by  far  the 
most  prominent  and  important  feature,  and  the  mental 
incapacity  subsides  into  relative  insignificance.  There 
is  no  sort  of  necessity  for  keeping  them  under  legal 
control,  for  they  are  already  sufficiently  under  control 
by  their  bodily  incapacity.  There  are  other  reasons 
why  it  may  be  inexpedient  to  place  or  keep  under  legal 
control  a  lunatic  to  whom  the  law  in  strictness  applies. 
It  by  no  means  follows  that  a  person  who  is  legally 
certifiable  as  a  lunatic  ought  to  be  certified,  and  for- 
tunately the  lunacy  law  is  administered  by  a  commission 
of  enlightened  men  who  recognise  that  what  is  legally 
requisite  is  not  always  expedient,  and  who  will  not 
enforce  the  strict  provisions  of  the  law  if  they  are 
satisfied  that  it  is  better  for  the  patient  that  they  should 
not  be  enforced. 

Again,  a  patient  may  be  insane  without  being  certi- 
fiably  insane — that  is  to  say,  although,  by  prolonged 
observation  of  his  conduct,  we  may  be  convinced  that 


320  A  TEXT-BOOK  OF  INSANITY 

his  mind  is  disordered,  and  that  he  is  no  longer  fully 
responsible  for  his  acts,  yet  we  may  be  unable  to  de- 
scribe in  words  any  specific  "  fact  indicating  insanity 
observed  at  the  time  of  examination,"  and  so  to  place 
him  under  control.  Such  persons  are  extremely  difficult 
to  deal  with  ;  and  though  they  often  eventually  become 
certifiable,  they  contrive,  before  this  stage  is  reached, 
to  run  through  large  sums  of  money,  often  to  ruin  them- 
selves, and  often  to  commit  criminal  acts. 

But  supposing  a  patient  to  be  certifiably  insane,  the 
first  questions  that  have  to  be  decided  are  whether  he 
may  properly  be  allowed  to  remain  uncertified,  whether 
he  should  be  placed  in  private  care,  or  whether  he  should 
be  sent  to  an  institution.  These  are  questions  that 
depend  partly  upon  the  nature  and  degree  of  the  malady, 
and  partly  upon  the  age,  wealth,  and  other  circum- 
stances of  the  patient. 

The  character  of  the  malady  is  the  most  important 
consideration.  It  may  be  stated  categorically  that 
every  case  of  acute  insanity  should  be  at  once  placed 
in  an  institution,  to  whatever  type  the  acute  insanity 
conforms,  and  to  whatever  variety  of  insanity  it  may 
happen  to  belong.  Every  patient  with  acute  insanity 
is  a  potential  suicide,  and  suicidal  patients  can  only  be 
prevented  from  effecting  their  purpose  by  asylum  treat- 
ment. It  is  only  in  an  institution  specially  constructed 
for  the  purpose  that  the  habit  of  incessant  supervision 
is  maintained,  and  that  the  appliances  for  heating  and 
lighting  and  ventilation,  the  staircases,  water-closets, 
bedsteads,  and  other  arrangements  are  specially  con- 
structed with  a  view  to  minimise  the  opportunities  for 
suicide.  Moreover,  patients  who  are  acutely  insane 
need  the  presence  of  a  medical  attendant  always  within 
call,  for  contingencies  requiring  instant  medical  treat- 


LEGAL  RELATIONS  321 

merit  are  of  frequent  occurrence  ;  and  it  is  obvious  that 
this  condition  can  be  secured  in  an  institution  only. 

For  a  somewhat  similar  reason,  general  paralytics 
invariably  require  to  be  detained  in  an  institution. 
They  are  subject,  throughout  the  whole  of  the  first, 
and  often  the  second  stage  also,  to  sudden  outbreaks  of 
violence,  to  deal  with  which  the  continued  presence  of  an 
adequate  stafi  of  attendants  is  necessary,  and  this  abun- 
dance of  attendants  is  only  obtainable  in  an  institution. 

Lastly,  all  paranoiacs  ought  to  be  detained  in  insti- 
tutions. All  such  patients  are  potential  homicides, 
and  scarcely  a  month  passes  without  the  commission 
of  a  murder  by  a  patient  of  this  description,  who  had 
given  abundant  evidence  beforehand  that  he  ought  to 
be  under  efficient  control. 

Patients  of  these  three  classes  ought  always  to  be 
treated  in  institutions,  but  they  are  not  the  only  patients 
for  whom  institution  treatment  is  necessary.  All 
patients  who  need  much  control  ought  to  be  in  institu- 
tions, for  only  in  them  can  much  control  be  exercised. 
Patients  who  are  very  noisy,  or  who  are  very  restless, 
or  who  are  sexually  excited,  cannot  be  properly  managed 
in  private  care. 

On  the  other  hand,  there  are  patients  w^ho  ought  not 
to  be  sent  to  institutions  if  this  course  can  be  avoided. 
Young  girls  or  young  lads  should  be  kept  out  of  insti- 
tutions as  long  as  possible,  for  the  fact  of  their  having 
been  placed  under  care  may  tell  very  seriously  against 
them  in  future  life;  quiet  dements  can  very  well  be 
treated  at  home  or  in  private  care  ;  and  persons  whose 
insanity  is  recent,  is  of  a  mild  and  sub-acute  form, 
ought  usually  to  have  a  trial  in  appropriate  surround- 
ings outside  an  asylum,  before  recourse  is  had  to  this 
extreme  measure. 


322  A  TEXT-BOOK  OF  INSANITY 

The  means  of  the  patient  form  a  very  important 
factor  in  determining  whether  he  shall  be  sent  to  an 
asylum  or  no.  In  the  case  of  a  poor  person,  no  other 
alternative  is  possible,  since,  apart  from  the  expense 
of  supervision,  the  mere  abstention  from  work  reduces 
them  to  a  condition  of  dependence  ;  while  wealthy 
men,  who  can  afford  plenty  of  attendants  and  an  isolated 
house  with  large  grounds,  can  very  well  be  treated  in 
their  own  homes.  There  are  multitudes  of  patients  in 
pauper  asylums  who,  if  they  possessed  adequate  means, 
might  be  at  large  ;  and  there  are  multitudes  of  persons 
at  large  who,  if  they  were  not  fortunately  in  possession 
of  means,  would  have  to  seek  the  shelter  of  an  asylum. 
It  is  a  very  common  occurrence  for  a  person  to  have 
sufficient  intelligence  to  administer  his  means  capably 
if  he  happens  to  possess  any,  and  yet  to  have  insufficient 
intelligence  to  earn  his  livelihood.  If  he  has  means,  he 
may  very  well  live  at  large,  but  if  he  has  none,  he  must 
be  cared  for  in  an  institution. 

If  it  is  determined  that  treatment  in  an  institution 
is  unavoidable,  or  is  desirable,  the  question  will  often 
arise  whether  he  should  be  placed  there  under  a  recep- 
tion order,  or  whether  he  should  go  of  his  own  free  will 
as  a  voluntary  boarder.  There  are  but  few  cases  in 
which  the  latter  alternative  is  really  the  best,  though 
it  is  often  practicable,  and  sometimes  the  only  practic- 
able course.  In  such  cases  the  patient  must  not  only 
be  willing  to  place  himself  under  care,  but  he  must  be 
competent  to  form  a  judgment  as  to  the  expediency  of 
doing  so,  and  he  must  be  to  such  an  extent  of  sound 
mind  that,  even  if  it  were  desirable,  it  is  not  possible 
to  make  a  certificate  of  lunacy  with  regard  to  him.  He 
must  be  uncertifiable. 

Neurologists,   who   are   frequently   consulted  about 


PLACING  UNDER  CONTROL  323 

cases  of  insanity,  though  it  is  a  subject  of  which  they 
have  no  special  knowledge,  almost  invariably  advise 
that  the  patient  should  travel,  and  are  particularly 
fond  of  recommending  a  sea  voyage.  Travelling  is, 
however,  almost  always  detrimental  in  the  early  stages 
of  insanity  ;  and  a  sea  voyage  is  probably  the  very 
worst  course  that  could  be  adopted.  As  already 
stated,  all  cases  of  acute  insanity  are  potential  suicides, 
and  on  board  ship  the  opportunity  and  temptation  to 
suicide  are  constantly  present  and  constantly  obtruded, 
and  effective  supervision  is  almost  impossible. 

There  are  four  occasions  on  which  a  medical  prac- 
titioner may  be  brought  into  contact  with  tke  law  in 
dealing  with  insane  persons  : — 

1.  In  the  placing  of  an  insane  person  under  control. 

2.  In  the  keeping  of  an  insane  person  under  control. 

3.  In  connection  with  the  validity  of  wills  and  con- 
tracts. 

4.  In  connection  with  responsibihty  for  criminal  acts. 
The    legal    formalities    necessary    for    depriving    an 

insane  person  of  the  management  of  himself  and  his 
afiairs,  and  for  detaining  him  under  care  and  treatment, 
differ  much  in  different  countries,  and  in  each  country 
in  different  cases.  The  procedure  is  different  in  England 
and  Wales,  in  Scotland,  and  in  Ireland. 

PLACING  UNDER  CONTROL 
m   ENGLAND   AND   WALES 

The  procedure  varies  in  the  following  circumstances  : — 

I.  According  as  the  patient  is  a  mentally  defective 
person  or  a  lunatic.  According  to  the  Lunacy  Act, 
1890,  a  lunatic  is  equivalent  to  a  person  of  unsound 
mind  ;    hence  the  law  dravrs  a  distinction  between  a 


324  A  TEXT-BOOK  OF  INSANITY 

person  who  is  mentally  defective  and  a  person  whose 
mind  is  unsound.  More  than  this,  by  the  Lunacy  Act, 
1890,  it  is  enacted  that  a  lunatic  means  an  idiot ;  but 
by  the  Mental  Deficiency  Act  an  idiot  is  one  class  of 
mentally  defective  persons.  The  practical  effect  of  this 
double  enactment  is  that  an  idiot  can  be  placed  under 
control  under  either  Act,  but  this  privilege  does  not 
extend  to  his  brother  who  is  an  imbecile.  The  intention 
of  the  Government  in  bringing  in  the  Mental  Deficiency 
Bill  was  to  codify  the  old  law  as  well  as  to  add  to  it  the 
new,  and  the  first  Bill  was  drafted  accordingly.  This 
Bill  had  to  be  dropped,  and  the  subsequent  Bill,  which 
is  now  the  Mental  Deficiency  Act,  leaves  the  old  Lunacy 
Law  in  force,  and  is  in  many  respects,  of  which  the 
enactment  with  regard  to  idiots  is  one,  incongruous 
with  the  old  law.  The  Mental  Deficiency  Act  applies 
to  those  persons  only  who  satisfy  the  definitions  in  the 
Act  of  the  several  degrees  of  mental  deficiency,  leaving 
all  other  classes  of  the  insane  under  the  old  law ;  and 
instead  of  one,  there  are  now  two  central  bodies  who 
supervise  the  working  of  the  Acts  relating  to  the  insane. 
The  Commissioners  in  Lunacy  continue  their  old 
functions,  and  the  Board  of  Control,  of  which  the  Com- 
missioners are  members,  administer  the  law  with 
respect  to  those  who  satisfy  the  definitions  of  defectives. 
The  arrangement  is  clumsy,  and  cannot  be  permanent, 
but  no  doubt  it  will  be  years  before  it  can  be  altered,  and 
in  the  meantime  I  must  give  an  account  of  it  as  it  is. 

The  following  classes  of  persons  are  mentally  defec- 
tive within  the  meaning  of  the  Mental  Deficiency  Act, 
1913  :— 

(a)  Idiots  ;  that  is  to  say,  persons  so  deeply  defective 
in  mind  from  birth  or  from  an  early  age  as  to  be  unable 
to  guard  themselves  against  common  physical  dangers  ; 


MENTAL  DEFECTIVES  325 

(h)  Imbeciles ;  that  is  to  say,  persons  in  whose  case 
there  exists  from  birth  or  from  an  early  age  mental  de- 
fectiveness not  amounting  to  idiocy,  yet  so  pronounced 
that  they  are  incapable  of  managing  themselves  or  their 
afiairs,  or,  in  the  case  of  children,  of  being  taught  to 
do  so  ; 

-  (c)  Feeble-minded  persons ;  that  is  to  say,  persons 
in  whose  case  there  exists  from  birth  or  from  an  early 
age  mental  defectiveness  not  amounting  to  imbecility, 
yet  so  pronounced  that  they  require  care,  supervision, 
and  control  for  their  own  protection  or  for  the  protection 
of  others,  or,  in  the  case  of  children,  that  they  by  reason 
of  such  defectiveness  appear  to  be  permanently  in- 
capable of  receiving  proper  benefit  from  the  instruction 
in  ordinary  schools ; 

(d)  Moral  imbeciles  ;  that  is  to  say,  persons  who  from 
an  early  age  display  some  permanent  mental  defect 
coupled  with  strong  vicious  or  criminal  propensities  on 
which  punishment  has  had  little  or  no  deterrent  efiect. 

A  mentally  defective  person  who  comes  under  any 
of  these  definitions  may  be  placed  in  an  institution  or 
under  guardianship 

(a)  at  the  instance  of  his  parent  or  guardian,  if  he  is 
an  idiot  or  an  imbecile,  or  at  the  instance  of  his 
parent  if,  though  not  an  idiot  or  imbecile,  he  is 
under  the  age  of  21  ;   or 

(h)  if  in  addition  to  being  a  defective  he  is  a  person 

(i)  who  is  found  neglected,  abandoned,  or  without 
visible  means  of  support,  or  cruelly  treated ; 

(ii)  who  is  found  guilty  of  any  criminal  offence,  or 
who  is  ordered  or  found  liable  to  be  ordered 
tp  be  ^ent  tp  a  certified  industrial  school  • 


326  A  TEXT-BOOK  OP  INSANITY 

(iii)  who  is  undergoing  imprisonment  (except  im- 
prisonment under  civil  process)  or  penal 
servitude,  or  is  undergoing  detention  in  a 
place  of  detention  by  order  of  a  court,  or  in 
a  reformatory  or  industrial  school,  or  in  an 
inebriate  reformatory,  or  who  is  detained 
in  an  institution  for  lunatics  or  a  criminal 
lunatic  asylum ;   or 

(iv)  who  is  an  habitual  drunkard  within  the 
meaning  of  the  Inebriates  Acts,  1879  to 
1900;  or 

(v)  in  whose  case  a  certain  notice  has  been  given 
by  the  local  education  authority  ;   or 

(vi)  who  is  in  receipt  of  poor  relief  at  the  time  of 
giving  birth  to  an  illegitimate  child  or  when 
pregnant  of  such  child. 

The  parent  or  guardian  of  a  defective  who  is  an  idiot 
or  an  imbecile,  and  the  parent  of  a  defective  who  is  not 
an  idiot  or  an  imbecile  but  is  under  21,  may  place  the 
defective  in  an  institution  or  under  guardianship.  Two 
medical  certificates  are  necessary,  one  of  which  must 
be  signed  by  the  medical  practitioner  approved  for  the 
purpose  by  the  local  authority.  In  the  case  of  an  idiot 
or  an  imbecile  these  are  all  that  is  necessary,  but  in  the 
case  of  a  feeble-minded  person  or  a  moral  imbecile 
there  must  be  in  addition  the  signature  to  both  certifi- 
cates of  a  judicial  authority  and  a  statement  by  the 
parent  or  guardian. 

If  the  defective  has  been  found  guilty  of  a  criminal 
offence,  he  may  be  dealt  with  under  an  order  of  the 
court  or  of  the  Secretary  of  State,  but  if  he  has  not  been 
convicted  and  if  there  is  no  parent  or  guardian,  or  if  for 
a^ny  reason  the  parent  or  guardian  does  not  act,  theri 


MENTAL  DEFECTIVES  327 

any  relative  or  friend  of  the  defective  or  any  ofi&cer  of 
the  local  authority  may  obtain  an  order  by  a  petition 
to  a  judicial  authority. 

The  petition  must  be  accompanied  by  two  medical 
certificates,  one  of  which  must  be  by  the  approved 
medical  practitioner,  and  must  be  accompanied  also  by 
a  statutory  declaration  made  by  the  petitioner  and  at 
least  one  other  person,  stating 

(a)  That  the  defective  is  a  defective  within  the 
meaning  of  the  Act,  and  to  which  class  of 
defectives  he  belongs  ; 

(6)  That  the  defective  is  subject  to  be  dealt  with 
under  the  Act,  and  the  circumstances  that 
make  him  so  subject ;   and 

(c)  whether  or  not  a  petition  under  the  Act  or  under 

the   Lunacy   Acts   has   previously   been   pre- 
sented, with  the  date  and  result ;  and 

(d)  If  the  petition  is  accompanied  by  a  certificate 

that  a  medical  certificate  is  impracticable,  the 
reasons  that  render  it  impracticable. 

It  will  be  seen  by  comparing  these  provisions  with 
those  set  out  below  as  required  by  the  Lunacy  Acts, 
that  the  difierences  are  that  under  the  Mental  Defectives 
Act  the  petition  must  be  accompanied  by  a  statutory 
declaration,  and  one  of  the  medical  certifiers  must  be 
approved  by  the  local  authority,  but  neither  need  be 
the  regular  medical  attendant  of  the  defective.  Under 
the  Lunacy  Acts  there  is  no  statutory  declaration,  there 
are  no  approved  medical  certifiers,  and  as  we  shall 
presently  see,  one  medical  certificate  must  be  made,  if 
possible,  by  the  regular  medical  attendant  of  the 
patient. 


328  A  TEXT-BOOK  OF  INSANITY 

II.  When  the  patient  does  not  come  under  the 
description  of  an  idiot  or  imbecile  from  birth  or  from 
an  early  age,  but  has  become  insane  in  later  life,  pro- 
cedure varies  according  to  the  following  circumstances: — 

1.  If  the  patient  is  wandering  at  large,  he  may  be 
arrested  by  the  police  and  taken  before  a  justice. 

2.  If  the  patient  is  not  wandering  at  large,  but  either 
is  not  under  proper  care  and  control,  or  is  cruelly  treated 
or  neglected  by  the  relative  or  other  person  having 
charge  of  him,  then  it  is  the  duty  of  the  police  and  the 
parish  authorities  to  give  information  on  oath  to  a  justice, 
who  will  then  take  the  necessary  legal  proceedings. 

3.  In  the  ordinary  case,  in  which  the  patient  is  living 
at  home  with  his  friends,  the  procedure  differs  according 
as  he  is  or  is  not  a  pauper,  by  which  is  meant  according 
as  his  means  allow  of  his  being  treated  as  a  "  private  " 
patient  and  of  his  support  being  paid  for,  or  as  his 
malady  must  be  treated  at  the  public  expense.  It  does 
not  mean  that  he  must  be  a  pauper  at  the  time  of  his 
certification  as  a  lunatic,  but  that  he  becomes  one  by 
being  certified  at  the  expense  of  his  parish. 

If  he  is  in  this  sense  a  pauper,  the  ai!air  is  managed 
by  the  relieving  officer,  and  the  only  duty  of  the  medical 
practitioner  is  to  make  a  certificate,  which  is  in  the 
same  form  whether  the  patient  is  a  pauper  or  a  private 
patient. 

If,  however,  the  patient  does  not  satisfy  any  of  the 
foregoing  descriptions,  but  is  a  private  patient,  not 
wandering  at  large  and  not  cruelly  treated  or  neglected, 
then  there  are  three  ways  of  placing  him  under  control, 
viz.  : — 

The  Judicial  Reception  Order, 

The  Urgency  Order,  and 

The  Inquisition. 


CEETIFICATES  OF  INSANITY  329 

The  first  is  the  ordinary  and  normal  procedure.  In 
order  to  procure  a  judicial  reception  order,  a  petition 
must  be  presented  by  the  nearest  relative  of  the  patient 
to  a  magistrate  specially  appointed  under  the  Lunacy 
Act,  1890  ;  and  the  petition  must  be  accompanied  by 
a  statement,  also  made  by  a  relative,  and  by  the  certifi- 
cates of  two  medical  practitioners  made  independently 
of  each  other — that  is  to  say,  the  certificates  must  be 
on  separate  sheets  of  paper,  and  the  examination  made 
for  the  purpose  of  certifying  must  be  made  "  separately 
from  any  other  practitioner." 

The  requirements  of  the  certificates  are  simple  and 
easily  satisfied,  but  it  is  seldom  that  they  do  not  con- 
tain some  gross  defect  that  could  have  been  avoided 
by  a  little  ordinary  care.  The  majority  of  certifjdng 
practitioners  do  not  even  trouble  to  refer  to  all  the 
marginal  notes  and  to  see  that  all  are  satisfied,  nor  do 
they  read  through  the  certificate  when  made,  to  delete 
redundant  words,  and  see  that  it  reads  grammatically 
and  logically  from  beginning  to  end. 

In  making  a  certificate,  its  purpose  must  be  con- 
stantly borne  in  mind.  It  is  to  satisfy  the  mind  of  the 
magistrate,  a  third  person,  who  has  never  seen  and 
knows  nothing  of  the  patient,  that  the  patient  is  insane 
and  a  proper  person  to  be  detained  imder  care  and 
treatment  as  an  insane  person.  Students  usually  make 
a  certificate  as  if  it  needed  to  contain  a  diagnosis,  or  as 
if  it  were  a  clinical  description  of  the  case,  and  accord- 
ingly they  put  among  the  "  facts  indicating  insanity  " 
their  observations  on  the  knee  jerks  and  the  pupillary 
reflexes,  and  the  age  and  complexion  of  the  patient. 
If  they  would  only  pay  attention  to  the  terms  of  the 
document,  and  remember  that  what  is  required  of  them 
are  "  facts  indicating  insanity  observed  by  myself  at 


330  A  TEXT-BOOK  OF  INSANITY 

the  time  of  examination,"  they  would  be  saved  from 
many  absurdities.  A  medical  certificate  of  lunacy  has 
by  statute  the  force  of  a  statement  made  upon  oath, 
and  therefore  should  be  drav/n  with  the  same  punctilious 
care  as  an  affidavit.  The  essentials  of  a  good  certificate 
are  three  : — 

1.  It  should  he  sufficient — that  is  to  say,  the  facts 
stated  as  indications  of  insanity  should  be  such  as  to 
carry  to  the  mind  of  the  magistrate,  who  has  never  seen 
the  patient  and  knows  nothing  of  him,  a  conviction 
that  the  patient  is  insane.  It  is  not  enough  for  the 
certifying  practitioner  to  satisfy  himself  on  this  point. 
He  must  so  state  his  facts  as  to  satisfy  the  magistrate, 
and  he  must  remember  that  the  magistrate  has  not  the 
knowledge  of  the  patient  that  he  himself  has.  To  the 
doctor,  who  knows  well  the  circumstances  of  his  patient, 
it  is  a  fact  indicating  insanity  when  the  patient  deplores 
his  own  poverty  and  ruin,  or  declares  that  his  wife  has 
deserted  him.  But  to  the  magistrate,  who  knows 
nothing  of  the  patient  or  his  circumstances,  these  state- 
ments do  not  carry  insanity,  for,  for  aught  he  knows, 
they  may  be  true.  When  the  "  fact  indicating  insanity  " 
does  not  carry  insanity  upon  the  face  of  it,  it  should 
be  supplemented  by  a  statement  that  it  is  incorrect, 
and,  if  need  be,  by  a  further  statement  that  the  patient 
continues  to  hold  it  in  spite  of  plain  evidence  to  the 
contrary.  That  "  he  thinks  his  wife  has  deserted  him  " 
is  of  itself  no  evidence  of  insanity  ;  but  that  "  he  thinks 
his  wife  has  deserted  him,  although  she  was  in  his  room 
ten  minutes  ago,  and  left  it  for  the  avowed  purpose  of 
posting  a  letter  "  is  evidence. 

2.  The  certificate  should  he  definite.  It  should  give 
"  facts  indicating  insanity,"  not  opinions  which  the 
certifier  mistakes  for  facts.     To  say  that  the  patient 


CERTIFICATES  OF  INSANITY  331 

"  feels  miserable,"  that  he  "  believes  he  has  committed 
the  unpardonable  sin,"  that  "  he  thinks  he  is  king  of 
the  world  "  are  not  observed  facts,  but  inferences  from 
observed  facts.  What  is  actually  observed  is  that  the 
patient  says  this  or  the  other.  Whether  his  mind 
is  in  accordance  with  his  statement  is  a  matter  of 
inference,  not  of  observation,  and  hence  the  statements 
in  a  certificate  should  be  limited  to  what  the  patient  says 
and  what  he  does,  and  should  not  ramble  into  w^hat  he 
thinks  and  feels.  Neither  has  the  certifier  any  business 
to  aver  that  the  patient  "  cannot  remember  "  this  or 
*'  will  not  answer  "  that.  All  that  he  can  observe  is  that 
the  patient  does  not  do  what  is  required  of  him.  Whether 
this  defect  is  defect  of  ability  or  defect  of  will  is  beyond 
his  power  to  determine.  When  you  are  giving  evidence 
upon  oath  you  must  distinguish  carefully  between  what 
you  observe  and  what  you  infer,  and  the  observation 
alone  can  be  legitimately  stated  as  a  fact. 

3.  Lastly,  the  certificate  must  he  clearly  expressed. 
Unless  you  are  a  master  of  English  composition,  keep 
your  sentences  short,  and  do  without  qualifying  clauses. 
Above  all,  avoid  entanglements  with  the  personal  pro- 
nouns. You  are  not  bound  to  give  any  "  facts  com- 
municated by  others."  If  the  facts  that  you  yourself 
observe  are  sufficient  to  prove  your  case,  there  is  no 
need  of  facts  communicated  by  others.  But  if  your 
own  facts  are  weak  and  need  corroboration,  then  you 
must  reinforce  them  by  communicated  facts  ;  and  never 
forget,  what  is  usually  forgotten,  to  give  the  name, 
Christian  names,  address,  and  description  of  your  in- 
formant. By  the  "  description  "  is  not  meant,  by  the 
way,  the  complexion,  colour  of  eyes  and  hair,  etc.,  of 
your  informant,  but  his  rank  in  life,  occupation  or  pro- 
fession.   Having  given  these  particulars  with  respect  to 


332  A  TEXT-BOOK  OF  INSANITY 

your  informant,  state  the  information  that  he  gives  you 
in  as  unambiguous  terms  as  possible,  making  it  clear 
to  whom  your  pronouns  refer.  Here  is  a  specimen  of 
the  kind  of  statement  that  ought  to  be  avoided  :  "The 
patient  states  that  he  knew  Mr.  M.  in  AustraUa,  and 
that  he  has  often  visited  him  at  his  house  there,  and 
that  on  one  occasion  he  went  into  his  house  and  ate  the 
dinner  that  had  been  prepared  for  him."  Who  was 
the  visitor,  whose  was  the  house,  and  whose  the  dinner 
are  here  left  in  uncertainty ;  and  it  is  obvious  that, 
on  one  reading  of  the  statement,  the  fact  that  one  man 
went  into  his  own  house  and  ate  his  own  dinner  is 
alleged  as  a  reason  why  another  man  is  to  be  considered 
insane. 

The  second  method  by  which  a  "  private  "  patient 
may  be  placed  under  control  is  by  means  of  an  urgency 
order,  but  this  method  is  purely  a  temporary  expedient 
to  obtain  immediate  control  of  a  patient  while  the  usual 
order  by  judicial  authority  is  being  obtained.  It  takes 
time  to  obtain  a  judicial  reception  order,  and  there  are 
cases  in  which  it  is  expedient  that  a  patient  should  be 
placed  under  control  at  once.  For  these  exceptional 
cases  the  urgency  order  is  provided.  By  its  means  a 
patient  can  be  placed  under  control  within  an  hour  or 
two,  and  the  urgency  order  will  remain  in  force  for 
seven  days,  or  if  within  seven  days  a  petition  for  a 
judicial  reception  order  is  presented,  then  until  that 
petition  is  disposed  of. 

The  urgency  order  must,  like  the  petition,  be  signed 
if  possible  by  a  near  relative  of  the  patient,  and  in  any 
case  the  person  who  signs  it  must  be  of  full  age,  and 
must  within  two  days  have  seen  the  patient.  It  must 
be  accompanied  by  one  medical  certificate,  and  by  a 
statement  of  particulars  sirailar  to  th^t  which  accogi- 


UBGENCY  CEBTIFICATES  333 

panics  a  petition.  In  addition  to  the  medical  certificate, 
which  is  in  precisely  the  same  form  as  those  which 
accompany  the  petition,  a  further  certificate  must 
be  given  by  the  medical  practitioner  in  the  following 
form  : — 

I  certify  that  it  is  expedient  for  the  welfare  of  the 
said  A.  B.  [or  for  the  public  safety,  as  the  case  may  be] 
that  the  said  A.  B.  should  he  forthwith  placed  under 
care  and  treatment.  My  reasons  for  this  conclusion  are 
as  follows  :  [State  them]. 

By  this  means  a  case  of  acute  mania  can  be  got 
under  control  at  once  ;  a  patient  who  is  taken  ill  in  an 
hotel  or  a  lodging-house,  or  who  arrives  insane  on  board 
ship,  can  be  immediately  taken  to  a  place  of  safety. 

The  inquisition  is  a  purely  legal  procedure,  and  the 
only  function  of  the  medical  practitioner  in  connection 
with  it  is  to  make  an  affidavit  and  to  give  evidence 
when  called  upon.  It  results  in  the  appointment  of  a 
committee  of  the  estate  to  administer  the  financial 
affairs  of  the  patient,  and  of  a  committee  of  the  person 
to  direct  how  the  patient  shall  be  cared  for,  and  to  be 
responsible  for  his  personal  welfare. 

IN  SCOTLAND 

Idiots  and  imbeciles  under  eighteen  years  of  age  may 
be  received  into  training  schools  in  Scotland  without 
even  the  small  formalities  which  are  needed  in  England 
and  Wales  ;  but  in  practice  all  such  cases  are  sent  to 
such  institutions  as  lunatics,  with  the  usual  formalities 
required  for  lunatics,  in  order  that  thereby  the  Govern- 
ment grant  may  be  obtained.  When  above  the  age  of 
eighteen  and  when  sent  to  institutions  other  than  train- 
ing schools,  idiots  and  imbeciles  are  classed  as  lunatics, 
and  are  subject  to  the  same  formalities. 


334  A  TEXT-BOOK  OF  INSANITY 

Insane  persons  whose  malady  is  not  confirmed  may  be 
placed  in  private  care  for  a  period  not  exceeding  six 
months,  under  the  certificate  to  that  effect  of  one 
medical  practitioner. 

Insane  persons,  whether  pauper  or  non-pauper,  can 
be  placed  in  institutions  upon  an  order  of  the  sheriff, 
which  is  obtained  by  petition,  accompanied  by  a  state- 
ment of  particulars  and  the  certificates  of  two  medical 
practitioners.  In  the  case  of  a  pauper,  the  petitioner  is 
the  inspector  of  poor. 

The  English  urgency  order  is  paralleled  by  a  certificate 
of  emergency  given  by  a  single  medical  practitioner, 
and  accompanied  by  a  request  from  the  person  in  the 
position  of  petitioner,  to  the  superintendent  of  the 
institution,  to  receive  the  patient. 

By  interdiction  a  person  who  is  prodigal  or  facile — 
that  is,  too  easily  influenced  by  others — can  be  restrained 
from  alienating  his  property  without  the  consent  of 
guardians,  called  interdictors,  who  are  appointed  by 
the  court.  This  provision  has  no  parallel  in  English 
law. 

The  English  inquisition  is  paralleled  in  Scotch  law 
by  the  proceedings  of  cognition  and  curatory.  The 
curator  appointed  by  the  court  administers  the  estate 
of  the  lunatic,  but  there  is  no  functionary  corresponding 
to  the  committee  of  the  person. 


IN  IRELAND 

The  formalities  differ  according  as  the  patient  is  to 
be  taken  to  a  district  asylum  or  to  a  licensed  or  un- 
licensed house. 

Pauper  patients  vjJio  are  not  dangerous  require  for  their 
admission  into  a  district  asylum  four  documents  : — 


PRACTICE  IN  IRELAND  335 

1.  Declaration  before  a  magistrate  stating  that  the 
patient  is  insane  and  destitute,  and  giving  the  names, 
addresses,  and  descriptions  of  two  relatives  of  the 
patient. 

2.  The  certificate  of  a  magistrate  and  of  a  clergy- 
man or  poor-law  guardian  that  they  have  personally 
inquired  into  the  case. 

3.  One  medical  certificate. 

4.  An  engagement  by  the  applicant  to  remove  the 
patient  when  called  upon  to  do  so. 

Paying  ^patients  who  are  not  dangerous  require  for 
admission  into  a  district  asylum  even  more  documents 
than  the  foregoing,  viz.  : — 

1.  A  declaration  before  a  magistrate  that  the  patient 
has  not  sufficient  means  to  pay  for  his  support  in  a 
Licensed  house,  and  has  no  friend  who  can  do  so  ;  and 
stating  how  long  the  patient  has  been  resident  in  the 
country. 

2.  The  certificate  of  a  magistrate  and  a  clergyman 
that  the  case  has  been  investigated. 

3.  One  medical  certificate  signed  by  two  medical 
practitioners. 

4.  An  engagement  to  remove  the  patient  when  called 
upon  to  do  so,  and  to  pay  a  specified  sum  for  his  support. 

5.  The  sanction  of  an  inspector  of  lunatics. 

As  might  have  been  expected,  proceedings  so  cum- 
brous are  in  practice  never  employed,  and  practically 
all  the  patients  in  the  district  or  public  asylums  of 
Ireland  are  admitted  as  dangerous  lunatics^  having  been 
apprehended  "  under  circumstances  denoting  derange- 
ment of  mind,  and  an  intention  of  committing  an  indict- 
able offence,"  and  removed  by  warrant  from  gaol  to 
the  asylum. 


336  A  TEXT-BOOK  OF  INSANITY 

Into  licensed  houses^  charitable  institutions,  and  single 
care  in  Ireland  patients  are  admitted  upon  the  following 
documents : — 

1.  An  order  by  a  relative  or  connection  of  the  lunatic. 

2.  A  medical  certificate  signed  by  two  medical 
practitioners. 

In  cases  of  urgency  the  signature  of  a  single  prac- 
titioner is  sufficient,  provided  that  a  second  be  added 
within  fourteen  days  of  the  first. 

The  proceedings  under  inquisition  are  practically 
the  same  as  in  English  law. 

In  connection  with  the  placing  of  an  insane  person 
under  control,  and  generally  in  connection  with  the 
examination  and  investigation  of  cases  of  insanity,  a 
warning  must  be  given  to  the  medical  practitioner 
never  under  any  circumstances  to  lend  himself  to 
deceit,  or  subterfuge,  or  cunning  devices,  in  dealing 
with  his  patients.  There  is  a  practice,  unhappily  still 
too  common,  of  regarding  persons  who  are  in  any  degree 
of  unsound  mind  as  if  all  the  ordinary  canons  of  truth 
and  honesty  were  dissolved  and  obliterated  in  as  far 
as  dealings  with  them  are  concerned.  They  are  apt 
to  be  looked  upon  as  beings  to  whom  everything  may 
be  lightly  promised,  and  with  whom  no  promise  need 
be  kept ;  who  may  be  shamelessly  deceived  without 
the  natural  consequences  of  deceit  being  incurred. 
Such  practices  are  utterly  inexcusable,  and  ought  on 
no  account  whatever  to  be  resorted  to.  When  a  patient 
is  to  be  examined  with  respect  to  his  state  of  mind,  the 
only  fair  and  proper  course  to  pursue  is  to  explain  to 
him,  if  he  is  sensible  enough  to  understand  the  explan- 
ation, what  the  object  of  his  visitor  is  in  subjecting 


KEEPING    UNDER'  CONTROL  337 

him  to  examination.  And  if  it  becomes  necessary  to 
remove  him  to  an  institution,  the  necessity  should  be 
pointed  out  to  him,  and  he  should  be  told  where  he  is 
going,  and  why.  If  he  objects,  he  should  be  reasoned 
with,  and  if  reasoning  and  persuasion  are  of  no  avail, 
he  must  be  told  that,  if  necessary,  force  will  be  em- 
ployed. Of  course,  if  he  is  not  sensible  enough  to  under- 
stand, this  procedure  need  not  be  adopted,  but  even 
then,  no  deceit  should  be  employed  to  gain  a  temporary 
advantage  at  the  certain  cost  of  much  subsequent 
trouble. 

KEEPING  UNDER  CONTROL 

The  law  with  regard  to  the  custody  of  insane  persons  is 
extremely  stringent,  and  in  these  days,  when  every 
medical  practitioner,  while  waiting  for  his  practice  to 
grow,  seeks  to  eke  out  his  income  by  taking  a  resident 
patient,  it  is  important  that  this  should  be  known.  The 
terms  of  the  Lunacy  Act,  1890,  are  as  follows  : — 

"  Subject  to  the  exceptions  in  this  Act  mentioned,  a 
person  .  .  .  shall  not  be  received  or  detained  as  a 
lunatic  .  .  .  as  a  single  patient,  unless  under  a  reception 
order  made  by  a  judicial  authority,"  etc. 

"  Every  person  who,  except  under  the  provisions  of 
this  Act,  receives  or  detains  a  lunatic  or  alleged  lunatic 
in  an  institution  for  lunatics,  or  for  pajonent  takes 
charge  of,  receives  to  board  or  lodge,  or  detains  a  lunatic 
or  alleged  lunatic  in  an  unlicensed  house,  shall  be  guilty 
of  a  misdemeanour,  and  in  the  latter  case  shall  also  be 
liable  to  a  penalty  not  exceeding  fifty  pounds." 

"Except  under  the  provisions  of  this  Act,  it  shall 
not  be  lawful  for  any  person  to  receive  or  detain  two  or 
more  lunatics  in  any  house  unless  the  house  is  an 
institution  for  lunatics  or  workhouse." 

"Any  person  who  receives  or  detains  two  or  more 
lunatics  in  any  house  except  as  aforesaid  shall  be  guilty 
of  a  misdemeanour." 


338  A  TEXT-BOOK  OF  INSANITY 

It  is  unlawful,  therefore,  to  receive  into  residence  a 
lunatic  or  alleged  lunatic  without  a  reception  order, 
and  only  one  such  patient  can  be  received  into  a  private 
house  even  with  such  an  order.  It  matters  not  whether 
a  profit  is  made  or  no.  Last  year  a  medical  man  was 
prosecuted  for  having,  for  payment,  taken  charge  of 
his  brother,  an  "  alleged  lunatic,"  for  having,  for  pay- 
ment, received  him,  and  for  having,  for  payment,  de- 
tained him  in  an  unlicensed  house.  It  was  proved  that 
the  Master  in  Lunacy  was  aware  of  and  approved  the 
arrangement,  and  it  was  proved  that  the  income  that 
the  medical  man  received  for  his  brother's  keep  did  not 
cover  the  charges  for  him,  but  nevertheless  the  de- 
fendant was  convicted  of  the  technical  ofience.  The 
important  question,  upon  which  the  whole  of  the  section 
practically  hangs,  is,  What  is  an  "  alleged  lunatic  "  ? 
Without  presuming  to  decide  a  legal  point,  it  may  be 
stated  that,  as  far  as  can  be  at  present  ascertained,  an 
''  alleged  lunatic "  probably  means  a  person  who  is 
certifiably  insane. 

If,  therefore,  a  medical  practitioner — or,  indeed,  any- 
one else — desires  to  receive,  for  payment,  a  patient  who 
is  certifiably  insane,  it  is  absolutely  necessary  that  he 
should  refuse  to  receive  the  patient  except  upon  a  judi- 
cial reception  order,  otherwise  he  may  find  himself 
liable  to  severe  penalties.  He  must  remember,  more- 
over, that  when  he  does  receive  a  patient  under  a 
judicial  reception  order,  he  is  at  once  responsible  for 
keeping  statutory  books  and  sending  statutory  notices 
and  reports,  that  he  must  submit  to  have  his  house 
periodically  visited  and  inspected,  and  his  domestic 
arrangements  criticised  and  reported  upon,  and  generally 
that  he  will  be  under  supervision,  and  responsible,  it 
may  be  to  more  than  one  authority,  for  every  detail  in 


TESTAMENTARY   CAPACITY  339 

the  treatment  of  his  patient.  The  numerous  duties  of 
record  and  report  cast  upon  the  person  who  has  charge 
of  a  patient  in  private  care  are  far  too  lengthy  to  set 
out  here,  and  will  be  found  in  detail  in  "  Lunacy  Law 
for  Medical  Men  "  (Churchill)  by  the  present  writer. 


TESTAMENTARY  AND  CONTRACTING  CAPACITY 

It  may  happen  to  any  medical  practitioner  to  be  called 
upon  to  give  evidence  as  to  the  capacity  of  a  testator 
to  make  a  valid  will.  It  is  not  infrequent  for  the  family 
medical  attendant  to  be  called  upon  to  witness  a  will, 
and  when  he  does  so  he  should  remember  that  he  does 
not  do  so  as  an  ordinary  witness,  whose  attestation  means 
merely  that  the  signature  of  the  testator  was  attached 
to  the  will  in  the  witness's  presence.  When  a  medical 
practitioner  attests  a  will,  his  attestation  means,  not 
only  that  the  testator  executed  the  will  in  his  presence, 
but  it  means  in  addition  that  the  testator  was  at  the  time 
of  sound  and  disposing  mind,  and  fit  to  make  a  will. 
The  attestation  of  the  medical  witness  is  a  certificate 
of  competency  given  to  the  testator. 

When  there  is  any  question  of  the  capacity  of  a  testa- 
tor, the  following  are  the  points  to  which  the  examining 
practitioner  should  give  his  consideration  : — 

L  Does  the  testator  understand  the  nature  of  his 
act  ? — that  is  to  say,  does  he  realise  that  he  is  making 
a  disposition  of  his  property  to  take  effect  after  his 
death  %  Does  he  know  whom  he  is  benefiting  and 
whom  he  is  excluding  from  benefit,  and  the  extent  to 
which  his  legatees  severally  benefit  under  his  will  ? 

2.  Does  he  understand  and  appreciate  the  nature 
and  extent  of  his  property  ?  It  is  not  essential,  of 
course,  that  he  should  be  acquainted  vvith  every  detail  if 


340  A  TEXT-BOOK  OF  INSANITY 

lie  is  a  man  of  large  property,  but  he  should  have  a 
general  knowledge  sufficient  for  the  purpose. 

3.  Does  he  comprehend  and  appreciate  the  nature 
of  the  claims  to  which  he  ought  to  give  effect  ? — that  is 
to  say,  has  he  a  clear  knowledge  and  recollection  of  the 
existence  of  the  persons  that  he  excludes  from  his  will, 
and  of  the  relation  in  which  they  stand  to  him  1  Has 
he  sufficient  intelligence  to  compare  the  claims  of 
different  people  upon  his  bounty  ?  And  lastly,  has  he 
any  such  disorder  of  mind  as  shall  "  poison  his  affections, 
pervert  his  sense  of  right,  or  prevent  the  exercise  of  his 
natural  faculties  "  ?  Has  he  such  insane  delusion  as  may 
"  influence  his  will  in  disposing  of  his  property,  and 
bring  about  a  disposal  of  it  which,  if  the  mind  had 
been  sound,  would  not  have  been  made  "  ?  To  vitiate 
the  disposing  power,  it  is  not  sufficient  that  the  testator 
should  suffer  from  delusion.  Many  insane  persons 
suffering  from  delusions  have  made  wills  which  have 
been  upheld  by  the  court.  To  destroy  the  "  disposing 
mind,"  the  testator  must  not  only  suffer  from  delusions, 
but  the  delusion  must  be  of  such  a  character  as  to  in- 
fluence him  in  the  disposal  of  his  property.  Contracting 
capacity  requires  the  same  conditions  mutatis  mutandis 
as  testamentary  capacity. 

Ceiminal  Responsibility 

The  third  occasion  upon  which  a  medical  practitioner 
may  be  brought  into  contact  mth  the  law  in  dealing 
with  an  insane  person  is  in  connection  with  criminal 
responsibility.  When  the  plea  of  insanity  is  raised  in 
a  criminal  case,  the  question  left  to  the  jury  is.  Did  the 
prisoner,  at  the  time  the  crime  was  committed,  know 
the  nature  and  quality  of  the  act  that  he  was  com- 


CRIMINAL   RESPONSIBILITY  341 

mitting  and  that  it  was  wrong  ?  What  amount  of  light 
the  medical  witness  will  be  allowed  to  throw  upon  this 
question,  supposing  that  he  can  throw  any,  will  depend 
upon  the  discretion  of  the  judge  who  tries  the  case, 
but  the  practice  nowadays  is  for  the  judge  to  allow  a 
very  wide  latitude  to  the  medical  witness,  and  for  the 
latter  to  state  his  opinion  very  freely.  In  doing  so  he 
should,  however,  not  allow  himself  to  be  influenced  by 
any  sentimentality  or  professional  prejudice  in  favour 
of  the  plea  of  insanity,  and  there  are  certain  practical 
precautions  which  it  is  his  duty  to  take.  In  his  inter- 
views with  the  prisoner  he  should  furnish  himself  with 
writing  materials  and  take  down  the  prisoner's  state- 
ments in  the  prisoner's  own  words  and  in  the  prisoner's 
presence.  He  will  then  be  entitled  to  refer  to  his  notes 
in  the  witness-box  in  order  to  refresh  his  memory.  He 
is,  of  course,  entitled  to  record  anything  that  the 
prisoner  may  say  about  the  crime  and  his  share  in  it, 
and  to  ask  him  consequential  questions  arising  out  of 
these  statements,  but  he  must  most  carefully  avoid 
asking  the  prisoner  whether  he  committed  the  crime, 
or  putting  to  him  leading  questions  implying  that  the 
crime  was  committed  by  him.  The  matter  comes  too 
rarely  into  the  practice  of  the  general  practitioner  to 
need  explanation  at  length  here,  and  those  who  desire 
to  pursue  it  will  find  it  treated  in  detail  in  any  book 
on  Criminal  Responsibility.  (Clarendon  Press.) 


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APPENDIX  B 

LETTERS  OF  INSANE  PERSONS 

In  many  forms  and  varieties  of  insanity  letters  are 
never  written.  In  other  forms  the  writing  of  letters 
forms  one  of  the  chief  occupations  of  the  patient,  and 
the  letters  are  often  very  characteristic. 

The  two  varieties  in  which  the  writing  of  letters  is 
most  characteristic  are  general  paralysis  and  paranoia. 
In  sub-acute  mania  also,  the  letters  written  are  often 
very  numerous. 

In  the  early  stage  of  general  paralysis,  the  letters 
are  very  numerous,  and  have  the  characteristics  already 
described.  They  very  often  contain  orders  for  the 
purchase  of  goods  in  great  quantity.  In  paranoia,  the 
writing  of  letters  is  usually  a  very  prominent  symptom, 
and  the  letters  are  often  of  an  extremely  insane  character 
when  Little  or  no  indication  of  insanity  can  be  obtained 
from  the  conversation  of  the  patient.  The  letters  some- 
times, but  by  no  means  always,  contain  references  to 
the  persecution  from  which  the  patient  believes  that  he 
suffers.  They  are  sometimes  neat  and  tidy,  but  more 
often  are  written  anyhow — first  a  body  of  writing  down 
the  middle  of  the  page,  then  the  margins  are  utilised, 
then  the  writing  is  crossed,  and  perhaps  recrossed  and 
interlineated.  When  all  the  paper  has  been  occupied 
in  this  way,  ragged  scraps  are  added,  old  envelopes  are 

345 


346  A   TEXT-BOOK   OF  INSANITY 

utilised,  margins  of  newspapers,  pages  torn  out  of  books, 
bits  of  paper  bags,  anything  in  the  shape  of  paper,  and 
finally  the  letter  is  concluded  on  the  flap  of  the  con- 
taining envelope,  and  often  on  the  outside  of  it  also. 
The  handwriting  is  usually  very  bad,  often  illegible,  and 
when  deciphered,  the  confusion  of  thought  so  character- 
istic of  paranoia  is  very  conspicuous — more  so,  usually, 
than  it  is  in  the  conversation.  Often  there  are  long 
strings  of  words  from  which  no  meaning  whatever  can 
be  extracted.  Sometimes  the  manuscript  is  varied  by 
sketches,  or  by  mysterious  symbols  and  diagrams.  The 
letters  are  usually  written  to  prominent  people  with 
whom  the  patient  has  no  acquaintance — to  the  sovereign, 
to  the  Secretaries  of  State,  to  foreign  potentates,  to 
prominent  politicians,  philanthropists,  actors,  athletes, 
to  anyone  whose  name  is  mentioned  in  a  newspaper. 


INDEX 

Reviewers  will  rejoice  greatly  to  find  no  index  to  this  book,  for 
its  absence  will  save  them  the  trouble  of  reading  the  book  to  discover 
whether  they  ought  to  award  to  it  praise  or  blame.  It  was  Carlyle 
who  first  erected  the  index  into  the  most  important  feature  in  a  book, 
and  made  the  presence  or  absence  of  an  index  the  criterion  of  literary 
excellence ;  and  subsequent  reviewers  have  followed  him  with  a 
unanimity  of  imitation  that  I  will  not  call  slavish,  but  that  certainly 
lacks  nothing  in  faithfulness.  Why  the  absence  of  an  index  should 
always  rouse  a  reviewer  to  fury  I  have  never  been  able  to  understand. 
It  is  no  necessary  adjunct  to  a  book,  and  many  books  that  were 
published  before  the  day  of  Thomas  Carlyle  are  allowed  to  have 
merits,  even  though  they  have  no  index.  There  is  no  index  to  the 
Iliad,  to  the  dramas  of  Sophocles  or  Euripides,  to  Euclid's  Elements, 
or  to  CiBsar's  account  of  the  Gallic  War.  There  is  no  index  to 
Shakespeare's  Plays,  to  Don  Quixote,  to  the  Pilgrim's  Progress,  or  to 
the  Novum  Organon.  Even  the  Bible  is  without  an  index.  AVhy, 
then,  should  the  absence  of  an  index  be  such  a  damning  fault  in  the 
eyes  of  the  modern  reviewer  ?  I  am  far  from  asserting  that  no 
book  should  have  an  index :  there  are  many  books  whose  usefulness 
would  be  sadly  impaired  if  an  index  were  wanting.  Such  are  BradshaAv's 
Railway  Guide,  the  Stores  Catalogue,  Whittaker's  Almanack,  books 
on  Case  Law,  and  other  hiblicc  ahihlia  ;  but  to  add  an  index  to  a  book 
on  a  single  subject — a  book  which  treats  that  subject  systematically 
and  orderly,  so  that  each  topic  is  in  its  proper  place,  and  can  be  found 
at  once  by  anyone  who  is  familiar  with  the  plan  of  the  work — seems 
to  me  nothing  short  of  an  insult  to  the  intelligence  of  the  reader. 
Apart  from  its  use  as  an  infallible  guide  to  the  judgment  of  the 
reviewer,  an  index  is  no  use  at  all  in  any  book  but  those  of  the  kind 
mentioned  above.  In  no  other  book  is  the  index  ever  consulted  ; 
at  any  rate,  I  have  never  myself  consulted  an  index,  nor  in  any  of 
the  books  that  I  have  in  past  years  borrowed  from  my  friends,  and 
supported  gratuitously  ever  since  upon  my  own  bookshelves,  have  the 
pages  containing  the  index  ever  been  opened,  either  before  or  after  my 
benevolent  assumption  of  their  care. 

347 


348  A   TEXT-BOOK   OF    INSANITY 

For  what  is  an  index  ?  It  is  an  apparatus  to  enable  a  reader  to  find 
any  given  topic  in  the  book.  To  add  an  index  to  a  book  that  is 
logically  arranged  is  to  take  it  for  granted  that  the  reader  is  not 
intelligent  enough  to  appreciate  a  logical  arrangement,  but  must  have 
the  topics  arranged  alphabetically  before  he  can  find  them.  When, 
therefore,  a  reviewer  complains  that  such  a  book  as  this  has  no  index, 
he  carries  his  complaint  to  the  wrong  quarter  ;  he  lays  the  burden  on 
the  wrong  shoulders.  His  grievance  lies,  if  he  did  but  know  it,  not 
against  the  author  of  the  book,  but  against  his  own  parents. 


WILLIAM   BRENDON   AND  SON,  LTUi 
PRINTERS.   PLYMOUTH 


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